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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Vascepa capsules. Findings: On review of the available documentation, this patient has a history of dyslipidemia and hypertension. The patients triglyceride level was noted to be elevated prior to starting treatment with Vascepa. Since starting treatment with Vascepa, the patients triglycerides have improved. A study reported that Vascepa was found to be superior to placebo in reducing triglycerides and cardiovascular events among patients with high triglycerides and either known cardiovascular disease, or in patients with diabetes plus significant cardiovascular risk factors. The records provided for review do not document a history of cardiovascular disease or diabetes to support an indication for treatment with Vascepa. Therefore, the Vascepa capsules was not and 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Ozempic. The records provided for review document that this patient has a history of type 1 diabetes complicated by end stage renal disease, hypothyroidism, and dyslipidemia. The patients provider reports that the patient has responded well to a combination of insulin and Ozempic in the past. The provider has recommended continued treatment with Ozempic, which is a member of a class of medications called glucagon like peptide 1 (GLP-1) receptor agonists, which have demonstrated effectiveness for hemoglobin A1C reduction with additional weight reduction and no intrinsic risk of hypoglycemic episodes. GLP-1 receptor agonists are recommended as the preferred first-line injectable glucose-lowering therapy for patients with type 2 diabetes, even before insulin treatment (Nauck, et al.). Recent data supports the use of a combined therapeutic regimen of insulin and GLP-1 receptor agonists for treating patients with type 1 diabetes mellitus. Combination therapy with GLP-1 and insulin can help achieve an ideal treatment effect on glycemic control, weight loss, and bolus insulin dose in patients with type 1 diabetes mellitus (Wang, et al.). Given this support, the requested Ozempic is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in 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 acromioplasty for the authorized right shoulder repair surgery. The records document that this patient is being treated for right shoulder primary osteoarthritis and biceps tenosynovitis as well as a small right shoulder rotator cuff tear. Physical examination of the right shoulder revealed tenderness to supraspinatus footprint and bicipital groove, and mild tenderness to the acromioclavicular joint. The records indicate that Hawkins, Neers, and Speeds tests were positive. The patient has undergone adequate attempts at conservative treatment modalities as documented in the providers notes. The addition of the recommended acromioplasty is supported as appropriate for this patient based on the current medical literature given the evidence of subacromial bursitis/subacromial impingement that has been refractory to conservative measures. Medical literatures reported that acromioplasty is a good surgical option for the treatment of shoulder impingement with an intact rotator cuff. All told, the requested acromioplasty for the authorized right shoulder repair surgery is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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

Findings:  The physician reviewer found that The patient has requested authorization and coverage for Xeljanz. The current medical evidence supports the requested medication in this clinical setting. This patient has failed treatment with high-dose infliximab despite adequate drug level and lack of anti-infliximab antibodies. Xeljanz (tofacitinib) has a different mechanism of action than aminosalicylates, immunomodulators, anti-tumor necrosis factor therapies, Entyvio, and Stelara. Xeljanz has been approved by the U.S. Food and Drug Administration for the treatment of ulcerative colitis. Sandborn and colleagues performed a double-blind, placebo-controlled trial of patients with moderate to severe ulcerative colitis. The authors noted, Patients with moderately to severely active ulcerative colitis treated with tofacitinib were more likely to have clinical response and remission than those receiving placebo. Studies have shown significant improvement in health-related quality of life and patient-reported outcomes with Xeljanz in patients with moderate to severe ulcerative colitis. American Gastroenterological Association (AGA) guidelines state, In adult outpatients with moderate to severe ulcerative colitis who have previously been exposed to infliximab, particularly those with primary nonresponse, the AGA suggests using ustekinumab or tofacitinib rather than vedolizumab or adalimumab for induction of remission. As this patient has already failed infliximab for ulcerative colitis, and has required ongoing corticosteroid therapy, there is sufficient support for Xeljanz in this setting. Therefore, Xeljanz 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.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Findings:  The physician reviewer found that An enrollees parent has requested authorization and coverage for occupational therapy (sensory integrative services). The records document that this patients primary diagnosis is autism. As is common with most patients with autism spectrum disorder, the patient has been impacted by multisensory processing abnormalities that began early in neurodevelopment and frequently interfere with the ability to perform activities of daily living. The patients provider states that the patient can benefit from sensory integration occupational therapy. As noted in the medical literature, no single pharmacotherapeutic approach can fully address the underlying causes for the deficits in patients with autism. Since sensory processing deficits are typically multifactorial in this patient population, tailoring a treatment regimen to the individual sensory processing deficits to improve function is critical. On review of the peer-reviewed clinical trials, sensory integration therapy is likely to be more beneficial for this patient than occupational therapy without the use of sensory integration (Kashefimehr, et al.; Randell, et al.). Given this support, the requested occupational therapy (sensory integrative services) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings: Two of the three physician reviewers found the requested occupational therapy (sensory integrative services) 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Wegovy. Findings: The records document that this patient presents with a history of obesity, obstructive sleep apnea (OSA), and prediabetes. The patient has attempted treatment with exercise and diet, with some improvement in hemoglobin A1C level. The patients provider has recommended treatment with Wegovy. Although lifestyle modification is recommended as the cornerstone of obesity management, many patients do not achieve long-lasting benefits due to difficulty with adherence as well as physiological and neurohormonal adaptation of the body in response to weight loss. Currently, there are multiple pharmacologic therapies are available to assist patients with weight management. Wegovy is a member of a class of medications known as glucagon like peptide 1 (GLP-1) agonists, which have been shown to improve glycemic control, reduce body weight, and decrease cardiovascular risk in obese patients. Multiple studies have demonstrated the ability Wegovy to promote weight loss, via reduced appetite and energy intake, as well as delayed gastric emptying. Given these findings, the requested Wegovy is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Sunosi. Findings: The U.S. Food and Drug Administration (FDA) has approved Sunosi for the treatment of patients with excessive daytime sleepiness associated with narcolepsy or OSA who are actively treated with continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP) but have residual excessive daytime sleepiness. However, Sunosi has not been shown to treat underlying obstructive sleep apnea (OSA). In addition, Sunosi has been determined to have potential side effects on the cardiovascular system, which dramatically increase in patients with untreated or undertreated OSA. Overall, there is a lack of studies demonstrating the safety and efficacy of Sunosi in the treatment of patients with severe OSA as in this patients clinical setting. On review of the medical literature, Sunosi is not indicated for treatment of this patients excessive daytime sleepiness secondary to untreated OSA. Therefore, the requested Sunosi tablets 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 internal medicine with subspecialty certification in sleep 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 a WalkAide System [functional electrical stimulator (FES) system]. There is a lack of evidence in current medical literature demonstrating that exposure to lower limb orthotic devices employing FES improves gait in persons with central neurological weakness. In a comprehensive review of the literature comparing FES-aided lower limb orthoses and conventional or mechanical orthoses, researchers reported that studies that directly compared ankle-foot orthotics (AFO) and FES did not indicate overall superiority of one over the other. The authors further noted that the evidence on AFO and FES improving gait kinematics was weak. While there are some potential benefits to exogenously stimulating lower limb effector muscles that have lost effective connections with the central nervous system, it is not evident that the potential benefits of FES-aided orthoses, such as a lighter weight and the potential of a decreased likelihood of skin breakdown, outweigh their disadvantages, such as a lack of stabilizing support during stance phase and potential for mechanical or technological complications including lead misapplication, lead failure or dislodgement, battery drainage or failure, and device failure. Given the lack of data supporting the use of the requested equipment as favorably altering neurological recovery, the requested equipment is not medically indicated. Therefore, a WalkAide System (FES system) 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 physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral total hip arthroplasty. Current medical literature supports the use of hip arthroplasty in obese and even morbidly obese patients. In a study including 295 total knee replacements and 195 total hip replacements, Sharrock and colleagues found that an increased body mass index (BMI) is not associated with an increased length of stay following surgery. Rather, the authors found that the morbidly obese had the shortest length of stay, and that re-admission rates and complications were commendable for patients with morbid obesity. The authors concluded that a BMI greater than 40 was not a contraindication to total knee or total hip replacement. Hung and colleagues found that while increased operative time, blood loss, and perioperative complications were seen in the morbidly obese patients, BMI alone was not an independent risk factor for a higher 30-day complication rate. The authors concluded that withholding total hip arthroplasty solely on the basis of BMI was not justified. In this clinical setting, as obesity in and of itself is not a contraindication for hip arthroplasty to relieve severe chronic symptoms, the requested service is medically indicated. Therefore, bilateral total hip arthroplasty 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 additional four in-person physical therapy sessions (for a total of eight in-person physical therapy sessions). This patient is reported to have persistent low back pain and sciatica following a fall down stairs in April 2021. The management of the patients condition can include pharmacological agents, rehabilitation, complementary medicine, and invasive approaches. The aim of rehabilitation is to reduce pain, reduce impairment, and improve the patients quality of life (Urits, et al.). Formal rehabilitative interventions can be rendered, in conjunction with education, towards a goal of self-management, independent exercise. Exercise and physical activity have low risks for adverse effects and are encouraged in the setting of this patients type of chronic pain (Chou, et al.; Geneen, et al.; Oliveira, et al.). The records provided for review do not establish that this patient has impairments that preclude participation in a fully independent exercise program to manage her symptoms. The exercises performed in the formal setting can be done independently or substituted with independent exercise. The benefit of passive modalities such as transcutaneous electrical stimulation, traction therapy, and massage/manual therapy on a formal basis over self-applied palliative modalities and independently rendered massage/manual therapy has not been demonstrated in the medical literature (Farber and Wieland; Binny, et al.; Gibson, et al.). For these reasons, the requested additional four in-person physical therapy sessions (for a total of eight in-person physical therapy sessions) are not medically necessary for 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 reimbursement for magnetic resonance imaging (MRI) of the right knee. Researchers do not recommend the systematic use of imaging in the diagnostic process in cases with typical clinical presentation of osteoarthritis, or the use of routine imaging in osteoarthritis follow-up. The authors further note that imaging abnormalities of osteoarthritis are commonly seen especially with increasing age. In this case, the patient has arthritis of the knees. Given that the submitted records did not document mechanical symptoms such as intermittent catching or effusion, and did not include a discussion of the trial and failure of conservative care, the service at issue was not medically indicated. Therefore, MRI of right was not medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the service at issue was not medically necessary for evaluation 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for PuraPly AM Wound Matrix applied during Mohs surgery. Treatment of basal cell carcinoma on the face can be safely and effectively performed by Mohs micrographic surgery. Repair of the defect can be accomplished through several means including secondary intention or primary intention including flaps or grafts. In this patients case, the size and location of the defect did not prevent either a flap or a graft from a donor skin site. The records do not document a clinical indication for PuraPly over an alternate option such as a flap or graft, which have been demonstrated to provide adequate cosmesis and functionality. The current peer-reviewed medical literature does not support use of skin substitutes such as PuraPly AM Wound Matrix for Mohs surgery (Lu, et al.). Thus, the PuraPly AM Wound Matrix applied during Mohs surgery was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings: Two of the three physician reviewers found the PuraPly AM Wound Matrix applied during Mohs surgery was 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 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 reviewer 1 is board certified in dermatology and is actively practicing. Physician reviewer 2 is board certified in dermatology and is actively practicing. Physician reviewer 3 is board certified in dermatology 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.