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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for an inpatient hospital stay. Kashkooe and colleagues note that length of hospital stay may be affected by several factors including age, gender, mechanism of injury, infection, type of injury, injury severity score, and surgery during hospitalization. In this case, the patient underwent reconstructive ankle surgery at a late hour and could not be discharged without pain control. As such, an overnight inpatient stay was medically indicated. Therefore, an inpatient hospital stay was medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested requested authorization and coverage for Xeljanz. Researchers noted that tofacitinib should be considered for the treatment of severe alopecia areata, alopecia totalis, and alopecia universalis. Researchers performed an open-label pilot study that included twelve patients with alopecia areata treated with Janus kinase (JAK) inhibitors. The authors found that only one patient demonstrated no regrowth. In this case, the patient has tried and failed standard steroid injections treatment, immunotherapy and methotrexate. Over the last three years, he has experienced rapidly progressing hair loss. Given the challenging pattern of this patients alopecia areata, and that he has tried and failed standard treatment, oral tofacitinib is the next step in on the treatment ladder. Therefore, Xeljanz is likely to be more beneficial for the treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested Xeljanz is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested medication is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in dermatology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic lab tests (CPT codes 81225, 81226, 81227, 81231). The records provided for review document that this patient underwent pharmacogenomic testing to assess the best therapeutic regimen to address her behavioral health issues. However, the routine use of pharmacogenetic testing is not recommended in depression treatment guidelines and medical literature (Malhi, et al.; Kennedy, et al.). The Clinical Pharmacogenetics Implementation Consortium (CPIC) published guidelines supporting the use of hepatic metabolizer status genotyping in dosing various antidepressants. However, the CPIC guidelines are not based on prospective randomized controlled trials comparing genetically guided medications with unguided regimens (Hicks, et al.). Pharmacogenomic testing has the potential to decrease treatment-emergent side effects and improve treatment response, as well as decrease inpatient admissions and readmissions due to lack of efficacy or side effects. Based on current peer-reviewed medical literature, additional research is needed to establish the clinical role of pharmacogenomic testing in this clinical setting. Accordingly, the genetic lab tests (CPT codes 81225, 81226, 81227, 81231) were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the genetic lab tests (CPT codes 81225, 81226, 81227, 81231) were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer 1 is board certified in genetics and is actively practicing. Physician reviewer 2 is board certified in genetics and is actively practicing. Physician reviewer 3 is board certified in neurology 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for dopamine transporter scan (DaTscan). The clinical diagnosis of classic Parkinsons disease is based on four primary features: bradykinesia, tremor, rigidity, or postural instability. While most patients present with clear clinical symptoms, there is a subset of patients who present with a less clear clinical findings or fail to respond to standard of care treatment (Seifert and Wiener). To facilitate in the differentiation between essential tremor and Parkinsons disease, the U.S. Food and Drug Administration approved DaTscan imaging technique. A prospective, observational study by Graebner and colleagues examined the impact of DaTscan in a movement disorder center over the course of 18 months. Clinical impacts were observed following imaging in a total of 24 patients, including changes in medications for 18 patients and psychological impacts for 11 patients. The authors concluded that DaTscan imaging may be a useful adjunct to clinical history and examination in well selected patients. In this case, the patient was noted to have a tremor with features of both essential tremor and parkinsonism. Based on current peer-reviewed medical literature, DaTscan was indicated to help differentiate between essential tremor and parkinsonism in this clinical setting. Therefore, the DaTscan was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the DaTscan was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in neurology 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for magnetic resonance imaging (MRI) (CPT 77046) of the right breast. Findings:  The physician reviewer found that Evaluation of the chest area after bilateral mastectomy and reconstruction is challenging. Mammogram is not recommended in the absence of breast tissue. Ultrasound has not been demonstrated to be as comprehensive or useful as MRI in this clinical setting. Post-mastectomy MRI in the setting of reconstruction has been shown to be the most effective modality for the detection of recurrent cancer, as well as other issues. In this patients case, the MRI was helpful to assist the provider in deciding whether a biopsy should be done, and if so, the location to biopsy. All told, the MRI (CPT 77046) of right breast was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.   Findings:  Two of the three physician reviewers found the MRI (CPT 77046) of right breast was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.   Final Result: The reviewers determined that the services at issue were likely to be more beneficial for evaluation 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 internal medicine with subspecialty certification in medical oncology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology 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: The patient has requested authorization and coverage for revision shoulder surgery to reconstruct a grade 5 acromioclavicular (AC) joint separation using a technique that uses a combination of polyester tape (Lockdown) and a distal clavicle hook plate (Synthes). Researchers noted that coracoclavicular ligament reconstruction by autologous plantaris tendon or allogeneic tendon graft combined with hook plate fixation for the treatment of acromioclavicular joint dislocation can achieve good effectiveness. Researchers found higher complication rates with loop suspensory fixation when compared to hook plating. In this case, the patients grade 5 AC separation was repaired with a coracoclavicular suture fixation that came apart with recurrent trauma. Due to the chronic nature of the separation, maximum fixation using both acromioclavicular and coracoclavicular will be necessary to compensate for the slow healing reaction and prevent disruption. As such, the requested services are medically indicated. Therefore, revision shoulder surgery to reconstruct a grade 5 AC joint separation using a technique that uses a combination of polyester tape (Lockdown) and a distal clavicle hook plate (Synthes) 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 physical therapy for the neck including traction, physical therapy for the right hip including traction, and physical therapy for the right shoulder. Findings:  The physician reviewer found that  records provided for review document that this patient has experienced chronic, widespread pain complaints that do not correlate well with her injury history or physical examination findings. She has undergone treatment with physical therapy without significant benefit. The records suggest that independent exercises and modalities are appropriate for this patient. While the patient has chronic symptoms, no marginal difference in clinical outcome is reasonably expected with formal physical therapy as compared to an independent exercise program, which has been shown to be an appropriate intervention in the setting of chronic pain related to fibromyalgia and other generalized musculoskeletal pain conditions. In addition, there is a paucity of current data demonstrating the long-term safety and efficacy of traction in the setting of neck pain, cervical radiculitis, and cervical radiculopathy. Traction has not been shown to be an effective adjunct or substitute for standard conservative care including exercise, stretching, topical thermal modalities, and analgesics. For these reasons, the requested physical therapy for the neck including traction, physical therapy for the right hip including traction, and physical therapy for the right shoulder 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for radiofrequency ablation (RFA). This patient presents with residual pain status post traumatic pelvic fracture. She has undergone multiple surgeries, including open reduction and internal fixation of the pelvic fracture, debridement of a left gluteus maximus infection, and partial hardware removal. Conservative treatment has included extensive physical therapy, a home exercise program, medications, activity modification, and RFA. Current evidence-based medical literature indicates that there is limited data supporting the safety and efficacy of RFA for long-term management of this patients chronic pain. Schmidt and colleagues concluded that RFA may offer a potential benefit as therapeutic modalities for sacroiliac joint pain, although limited data supports the use of this procedure as a primary treatment modality. Yang and colleagues reported that current evidence suggests that RFA can provide relief of pain that originates from the posterior sacroiliac joint complex, but interpretation of this literature is limited by variability in patient selection criteria, the specific nerves targeted for ablation, and the types of RFA technology and technique utilized. In this patients clinical setting, there is a lack of clinical documentation from the provider including a current pain assessment, functional assessment, or sacroiliac joint pain or positive provocative testing to support an indication for RFA to the left sacroiliac region. For these reasons, the requested RFA 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 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: The patient has requested authorization and coverage for a transcatheter aortic valve replacement (TAVR) procedure. Mack and colleagues found that among patients with severe aortic stenosis who were at low surgical risk, the rate of the composite of death, stroke, or rehospitalization at one year was significantly lower with TAVR than with surgery. In this case, the patient has severe symptomatic aortic stenosis. He has several comorbid conditions, including obesity and sleep apnea with use of CPAP, that put him at higher surgical risk and would make surgical valve replacement less safe. Therefore, a TAVR procedure 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 internal medicine with sub-specialty certification in cardiovascular 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 patient has requested authorization and coverage for fertility preservation services including intracytoplasmic sperm injection (ICSI), oocyte fertilization, embryo development, and subsequent embryo cryopreservation with PGD screening. Sperm and embryo cryopreservation as well as oocyte cryopreservation are considered standard of care for patients who plan to undergo treatment for cancer, which is expected to result in iatrogenic infertility. Fertility preservation options in females depend on a patients age, diagnosis, type of treatment, presence or participation of a male partner and patient preferences regarding the use of banked donor sperm, time available, and likelihood that cancer has metastasized to her ovaries. The records provided for review document that this patient plans to undergo treatment with chemotherapy and radiotherapy. Thus, she is at very high risk of developing ovarian failure due to the gonadotoxic treatment modalities. In addition, this patient may require removal of her ovaries surgically to decrease her risk for ovarian cancer. The standard of care is to proceed with in vitro fertilization (IVF) and oocyte or embryo cryopreservation. Given the presence of a BRCA mutation in this patient, performing PGD on embryos and selecting non-affected embryos to transfer is appropriate to help prevent the birth of a child affected with a BRCA mutation. For these reasons, the requested fertility preservation services including ICSI, oocyte fertilization, embryo development, and subsequent embryo cryopreservation with PGD screening are 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 obstetrics and gynecology with subspecialty certification in reproductive 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 Tecfidera (dimethyl fumarate).The submitted documentation supports that the requested medication is medically necessary. Tecfidera (dimethyl fumarate) is indicated for the treatment of patients with relapsing forms of multiple sclerosis at a starting dose of 120 mg twice daily for one week, followed by maintenance dosage of 240 mg twice daily. The American Academy of Neurology practice guideline recommendations for disease-modifying therapies (DMTs) for adults with multiple sclerosis include respecting and evaluating patient preferences to improve acceptance of and adherence to DMTs. Patient preferences may include the safety, route of administration, lifestyle, efficacy, common adverse effects, and tolerability in the choice of DMT. In two large trials, an oral formulation of dimethyl fumarate (BG-12) significantly reduced relapse rates and the development of new brain lesions on MRI in patients with active multiple sclerosis. The safety of the three oral agents approved by the Food and Drug Administration for the treatment of relapsing-remitting multiple sclerosis were reviewed by researchers, and they concluded that the main risks marked with dimethyl fumarate were flushing and gastrointestinal events.In this case, the patient has a diagnosis of relapsing remitting multiple sclerosis. The provider presented and weighed options for DMT and determined that Tecfidera would be most effective, considering the route of administration, its efficacy and safety for the patient, and the patients preference to avoid injectables. Based on the current medical literature, Tecfidera has an efficacy that is superior to or comparable with the other approved DMTs such as Extavia, Glatopa, and Gilenya, and its safety profile is potentially less harmful than Gilenya, the other oral alternative. Therefore, the requested medication, Tecfidera (dimethyl fumarate), 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 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.