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 tertiary level of care services for eye care. The records provided for review document that this patient has a number of active clinical problems that are likely to affect her eye health. The provider charted a history of thyroid eye disease without significant proptosis and dry eye disease with concomitant signs of inflammation. In addition, the patient has a history of positive anti-nuclear antibody (ANA), although a low titer, which is consistent with an autoimmune process. Thyroid eye disease is oftentimes associated with dry eye disease. The provider noted concern for Sjogrens syndrome, which may be difficult to diagnose in the early stages, but there may be subtle signs on physical examination. Based on these ongoing active issues, it is medically reasonable for this patient to undergo a tertiary level consultation for her eye disease. Given these findings, the requested tertiary level of care services for eye care 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 ophthalmology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Taltz.Findings: Chronic plaque psoriasis is a disease that affects quality of life. In recent years, biologic medications like Taltz have been shown to control disease safely for the vast majority of patients. Taltz (ixekizumab) is approved by the U.S. Food and Drug Administration for the treatment of chronic plaque psoriasis. According to the joint guidelines for the treatment of psoriasis from the American Academy of Dermatology and the National Psoriasis Foundation, ixekizumab is recommended as a monotherapy treatment option for use in adult patients with moderate-to-severe plaque psoriasis. Multiple randomized controlled trials evaluating ixekizumab versus placebo establish the efficacy of this drug in patients with moderate-to-severe psoriasis. Additionally, at four weeks, the psoriasis area and severity index (PASI) score, a measure of improvement, is significantly better with ixekizumab than Enbrel. In this case, the patient is already taking Taltz and is doing well. Additionally, the patient has tried and failed Otezla. Therefore, Taltz is medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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 parent of an enrollee has requested authorization and coverage for laboratory testing (CPT codes 82784, 82787 and 83520).Oral food challenges and oral food desensitizations have been performed successfully by allergists and immunologists. While oral food desensitization has been achieved in the majority of individuals in randomized controlled studies, few go on to develop `tolerance` or sustained unresponsiveness to the allergic stimulant. It is the standard of care to measure immunoglobulin E (IgE) levels to specific foods in question for a patient. However, an extensive array of blood tests examining foods to which a patient has not had a reaction to and proceeding with oral desensitization to a multitude of foods to which there is no history of anaphylaxis is not supported by the medical literature. In this case, the requested laboratory testing (quantitative immunoglobulin (CPT 82784), immunoglobulin G (IgG) subclasses (CPT 82787), and immunoassay for analyte (CPT 83520)) is not supported by the medical literature. Furthermore, while oral food challenges are medically appropriate to rule out immunoglobulin E (IgE) mediated food allergy, there is a lack of evidence supporting oral dosing protocols for foods that are considered intolerances or IgE mediated allergies based on IgG and patch testing. Therefore, the requested laboratory testing (CPT codes 82784, 82787 and 83520) is not medically necessary for the evaluation of the patients medical condition. 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 allergy and immunology 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 enrollees parent has requested reimbursement for Autonomic nervous system testing. The records document that this patient presented to her provider with symptoms of fatigue and lightheadedness. She was diagnosed with a disorder consisting of autonomic dysfunction in the spectrum of postural tachycardia. The patients symptoms were consistent with orthostatic intolerance of unknown etiology. In this clinical setting, autonomic screen testing is a well-established battery of tests to evaluate patients when the underlying cause is unknown. The purpose of the tests is to confirm that the patient has autonomic dysfunction, determine the severity of the dysfunction, and determine whether the patient has underlying autonomic failure causing the symptoms. There are no options available to evaluate a patients symptoms other than autonomic testing and the results of these tests are actionable. There is longstanding support for these tests from the American Academy of Neurology (AAN), American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM), and American Academy of Physical Medicine and Rehabilitation (AAPMR) for this type of testing in evaluation of autonomic dysfunction of unknown etiology. Moreover, recent reviews in the medical literature also support autonomic nervous system testing as generally accepted standards of medical practice in this clinical situation. All told, the autonomic nervous system testing 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 autonomic nervous system testing 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 with special qualification in child 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for computer-assisted surgical navigation (CPT code 20985) provided at Seaside Surgery Center. To date, there is a lack of data documenting improvement in patient outcomes with the use of robotics and navigation during partial or total knee arthroplasty (TKA). Jones and Jerabek note that missing from a review of current literature on the role of computer-assisted surgical navigation in TKA were any conclusive demonstrations of clinical superiority in terms of improved patient-reported outcome measures and/or decreased cumulative revision rates in the long term. Lee and colleagues found no significant differences in clinical or radiological outcomes between computer-navigated TKA and conventional TKA. Kim and colleagues concluded, In this randomized trial, with data presented at a minimum of 14 years of follow-up, we found no benefit to computer navigation in TKA in terms of pain, function, or survivorship. Unless another study at long-term follow-up identifies an advantage to survivorship, pain, and function, we do not recommend the widespread use of computer navigation in TKA because of its risks (in this series, we observed femoral notching; others have observed pin site fractures) and attendant costs. The current scientific evidence does not support the use of computer-assisted navigation as more beneficial for the treatment of knee arthrosis by partial or total arthroplasty than standard arthroplasty without navigation. Therefore, the computer-assisted surgical navigation (CPT code 20985) provided at Seaside Surgery Center was not likely to have been more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the computer-assisted surgical navigation (CPT code 20985) provided at Seaside Surgery Center at issue was not likely to have been more beneficial for treatment 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 treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in orthopedic surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Euflexxa injection series in both knees.An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has had good lasting relief from prior viscosupplementation on multiple occasions in the past. The patient has tried other conservative treatments, such as NSAIDs, with the alternative being bilateral total knee arthroplasties. Therefore, Euflexxa injection series in both knees are medically necessary for the treatment of the patients medical condition.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 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 lumbar artificial disc replacement surgery. Findings: There is a lack of evidence in current medical literature supporting the efficacy and long-term effects of multi-level lumbar artificial disc replacement in patient outcomes. A study notes that there is insufficient evidence to show that lumbar total disc replacement is superior to fusion surgery. Another study reported that while further advancement and studies are warranted to assess the long-term durability and sustainability of lumbar disc arthroplasty, it is an acceptable alternative within the surgical armamentarium for selected patients. In this case, the records document facet arthropathy and foraminal stenosis due to facet hypertrophy. Given the high rate of failure of artificial discs in this clinical setting, the requested services are not medically indicated. Therefore, lumbar artificial disc replacement surgery are not medically necessary for the 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Duexis. The current medical literature and guidelines regarding treatment with NSAIDs in patients at high risk for gastrointestinal toxicity recommend co-therapy with misoprostol, histamine type-2 receptor antagonists or proton-pump inhibitors (PPIs) and/or cyclooxygenase-2 (COX-2) selective inhibitors. The records provided for review document that this patient has chronic wrist pain due to degenerative joint disease. The patient has been treated with steroid injections and NSAID therapy including ibuprofen, acetaminophen, and Naproxen, but these were stopped due to gastritis. However, there is a lack of documentation that the patient was concurrently treated with stomach protecting agents with use of NSAIDs. The current data supports use of a selective COX-2 inhibitor anti-inflammatory agent in combination with a proton pump inhibitor or a type two histamine blocking medication to reduce the risk of gastrointestinal side effects. The medical literature has not demonstrated that Duexis is superior to treatment with ibuprofen 800 mg with famotidine 80 mg in combination as single agents. All told, the requested Duexis (ibuprofen and famotidine) tablets 800 mg/26.6 mg are 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 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: An enrollee has requested authorization and coverage for a Synvisc (hyaluronan) injection series in the right knee.Findings: An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has had good benefit from viscosupplementation with Synvisc-One in the past, although Orthovisc did not provide relief. Furthermore, the options are limited, and the patient wants to postpone total knee arthroplasty. Therefore, the requested Synvisc (hyaluronan) injection series in the right knee is medically necessary for the treatment of the patients medical condition.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 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 an encephalomyosynangiosis procedure, placing a sternomastoid muscle flap on the posterior part of the brain. The treatment option for Moyamoya is generally surgical, with surgical options including direct and indirect cerebrovascular bypass. while surgical revascularization does not significantly change the underlying pathogenic mechanisms, it plays a pivotal role in the management of patients with Moyamoya disease, allowing for a decrease in the risk of ischemic and hemorrhagic complications. In this case, the patient has a diagnosis of Moyamoya and is status post bilateral external carotid to internal carotid system (EC/IC) bypasses. The records document a notable stenosis at the anastomosis on the right side along with a perfusion deficit, and a history of transient ischemic attacks (TIA). Given that this patient has progressive symptoms possibly related to hypoperfusion from stenosis at her previous direct bypass site, the requested service is medically indicated. Therefore, an encephalomyosynangiosis procedure, placing a sternomastoid muscle flap on the posterior part of the brain, 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Orthovisc injection series in both knees.Findings: An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, prior viscosupplementation was beneficial. Furthermore, the patients options are limited. The patient has tried and failed other conservative treatments, with the alternative being bilateral total knee arthroplasties. Therefore, Orthovisc injection series in both knees are medically necessary for the treatment of the patients medical condition.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 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 Viibryd 80 mg (40 mg twice a day). As noted in the medical literature, Viibryd can be safe and effective when dosed up to 80 mg daily when taken in conjunction with metabolic inducers. This patients provider noted that the patient is an ultrarapid metabolizer of medications, which is considered a similar clinic scenario. In addition, Wang and colleagues reported on several non-published studies of Viibryd that have demonstrated safety in the medication even when dosed up to 100 mg daily. This patient has been managed on Viibryd 80 mg daily without adverse effects for her treatment-refractory depression. In addition, the patient has failed treatment with numerous medical therapies in the past, even at the highest recommended doses. Given the clinical effect without adverse effects and the patients long history of treatment-refractory major depressive disorder, continued treatment with Viibryd at 80 mg daily is consistent with current recommendations. Therefore, the requested Viibryd 80 mg (40 mg twice a day) 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 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.