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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of pelvis and right knee.According to Lang and colleagues, isolated pelvic fractures following trauma are rare, accounting for approximately 3-6% of all fractures. The authors further state, In patients with adequate trauma, MRI is of low value. Additionally, Khurana and colleagues indicate a pelvic MRI is rarely indicated for patients with acute pelvic trauma. Currently, there are no clear criteria for pelvic MRI for acute trauma because it is not indicated. In this case, the patients injury occurred over two weeks prior to the patients office visit. It is unlikely that the patient has an isolated pelvic fracture. This patients pain was focused in the areas of the lower spine and the right hip. MRI examinations of the bony pelvis have specific indications, most commonly for the evaluation of groin pain, bilateral hip pain in the setting of suspected osteonecrosis, impingement syndromes, metastatic disease or lumbosacral plexus imaging. Due to the fact that the pelvic ring is a very stable structure, reinforced by ligaments, unless there is suspicion of occult fracture secondary to significant pelvic trauma, there is little value in MRI of the bony pelvis aside from those listed above. MRI of the pelvis is of little value in this situation. Therefore, MRI of pelvis is not medically necessary for evaluation of the patients medical condition.According to the American College of Radiology appropriateness criteria for the evaluation of acute knee trauma, the best initial imaging examination is radiographs. If initial imaging is negative and occult fracture or internal derangement is suspected, then MRI may be indicated. In this case, radiographs were negative and internal or ligamentous injury is suspected. Therefore, MRI of the right knee is medically necessary for evaluation of the patients medical condition.Final Result: The reviewer determined that a portion of the requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in diagnostic radiology 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 unilateral cochlear implant. The U.S. Food and Drug Administration (FDA) approved MED-ELs cochlear implant for single-sided deafness (SSD) and asymmetric hearing loss (AHL) for patients five years of age and older in 2019. However, to fully meet criteria for cochlear implant for this indication, the FDA requires that individuals with SSD or AHL must have at least one (1) month experience wearing a Contra Lateral Routing of Signal (CROS) hearing aid or other relevant device and not show any subjective benefit. The documents submitted for review do not demonstrate that the patient used a CROS hearing aid, bone-anchored hearing aid (BAHA), or other relevant hearing aid for 1 month. There are few studies comparing cochlear implants with other rehabilitative interventions, such as an air-conduction CROS hearing aid or BAHA. Medical literature found that a BAHA was more efficacious than CROS hearing aids in patients with unilateral severe-to-profound hearing loss, and that cochlear implants, BAHA, and CROS hearing aids all improved hearing-related quality of life. However, the meta-analysis could not support that cochlear implants were more beneficial than BAHA or CROS hearing aids. Medical literature reported on a combined prospective randomized controlled trial of patients with single-sided deafness or asymmetric hearing loss who were initially provided CROS and headband-based bone-conduction hearing aids. The authors found that cochlear implants, BAHA, and CROS devices all improved quality of life. This patients clinical documentation does not support that the patient is not a candidate for treatment with a BAHA for the treatment of unilateral hearing loss. All told, the requested unilateral cochlear implant is not medically necessary for this patient. Final Result: The reviewer determined that the requested device 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 otolaryngology 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 infliximab (Inflectra), dosed at 22 mg/kg given every two weeks for two to four treatments. Assa and colleagues note that it is common for patients with very early onset inflammatory bowel disease (VEO-IBD) to require higher than standard doses of infliximab. Bramuzzo and colleagues report that while there are very few data regarding the use of infliximab in children with VEO-IBD, compared with older children, VEO-IBD patients have higher rates of infliximab failures, lower remission rates at one year, and more often experience adverse events during induction.  In this case, the patient has VEO-IBD that has not responded to steroids, enteral nutrition therapy, or vedolizumab.  He has received multiple infusions of infliximab, at an escalated dose and frequency, showing slight symptomatic improvement for roughly one week after each dose. Infliximab trough levels checked at the four week point were sub-therapeutic, in the 3 to 4 mcg/mL range, whereas a level of 10 to 12 would be more appropriate. The patients temporary and incomplete symptomatic improvement after infliximab treatment may be indicative of a response, which he is unable to sustain due to either rapid metabolism or rapid clearance. Knowledge of whether this patient has true primary non-response to infliximab will be important for ongoing selection of medications as in the setting of primary non-response, further trials of anti-tumor necrosis factor (TNF) medications are likely to prolong treatment without any benefit and may simply delay the process of choosing other agents or proceeding to surgery, whereas if there is response to high-dose infliximab, the patient may be able to decrease his dose after intestinal inflammation decreases and drug loss through the intestinal wall is slowed as opposed to transitioning to a different anti-TNF agent. In this clinical setting, given the lack of multiple treatment alternatives, the short-term trial of frequent high doses of infliximab is medically indicated for the treatment of this patients persistent, moderate-to-severely symptomatic VEO-IBD. Therefore, infliximab (Inflectra), dosed at 22 mg/kg given every two weeks for two to four treatments is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication regimen 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 pediatrics with sub-specialty certification in pediatric 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral lumbar epidural injections at L5-S1. Findings:  The physician reviewer found that American Society of Interventional Pain Physicians  (ASIPP) guidelines for epidural steroid injections addressed approaches to repeat injections (Manchikanti, et al.). The authors noted that repeat injections should be based on, The administration must be based solely on patients response, the safety profile of the drug, experience of the patient, and pharmacological and chemical properties such as duration of action and suppression of adrenals. Regarding procedural outcomes, the ASIPP guidelines state that, In the therapeutic phase (after the diagnostic phase is completed), the suggested frequency of interventional techniques should be two and a half to three months or longer between each injection, provided that greater than 50% relief is obtained for two and a half to three months, not exceeding four per year, per region. In this case, the patient has lumbar radiculopathy affecting the left greater than the right lower leg and MRI evidence of multilevel degenerative disc disease and joint disease causing moderate grade foraminal stenosis at the lower two lumbar levels. The patient underwent epidural injections, which yielded pain relief for only three weeks, and on the left side with 80% relief for six weeks. The patients provider has recommended lumbar epidural steroid injection six weeks after the last one was completed. Although the patients response to the injection therapy has been clinically relevant, the documented duration of benefit was not at least three months. The ASIPP guidelines state that repeat injections may be considered when the patient reports at least 50% pain relief for at least three months, which was not documented in this patients case. Accordingly, the requested bilateral lumbar epidural injections at L5-S1 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Euflexxa injections of the right knee. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as routine treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, there is no history of prior viscosupplementation. However, the patients remaining treatment options are limited, and a corticosteroid injection was only effective for a few days. Furthermore, the patient does not wish to undergo total knee arthroplasty for the treatment of mild osteoarthritis. Given this support, the requested Euflexxa injections of the right knee 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 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 overage for brand name Lotemax 0.5% ophthalmic suspension. Medical literature note that dry eye disease is a common ocular condition that may be effectively treated by topical corticosteroids. The authors further note that loteprednol (brand name Lotemax) is safe and well tolerated, with minimal effects on intraocular pressure. Loteprednol is a type of synthetic steroid with advantages over standard steroids, such as dexamethasone and prednisolone, as it acts mostly on the surface of the eye and does not lead to cataract development, which may be a side effect of standard steroids. In this case, the records noted that the patient had tried both the generic and brand formulations of loteprednol, and reported that her symptoms were better using the brand formulation. This is consistent with brand name Lotemax having a much lower concentration of the preservative benzalkonium chloride, which can be irritating to the surface in dry eye patients, than the generic formulation. Given this patients ongoing need for steroids and as the records note more symptomatic relief with brand name Lotemax, the requested medication is medically indicated. Therefore, brand name Lotemax 0.5% ophthalmic suspension 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Revlimid (lenalidomide) combined with dexamethasone and daratumumab to be administered over an initial six-month period and forward. Findings:  The physician reviewer found that the patient has smoldering multiple myeloma without calcium, renal failure, anemia, and bone lesion (CRAB) symptoms. Per the provider, prior treatment Revlimid in July 2020 resulted in transaminitis. The patients provider has recommended treatment with Revlimid with dexamethasone and daratumumab. However, daratumumab in combination with lenalidomide and dexamethasone is not U.S. Food and Drug Administration (FDA) approved for the treatment of smoldering multiple myeloma. Moreover, this medication regimen is not supported by major drug compendia or the medical literature. Landgren and colleagues reported that their findings support monotherapy with daratumumab in this clinical setting. Given these findings, the requested Revlimid (lenalidomide) combined with dexamethasone and daratumumab to be administered over an initial six-month period and forward is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication regimen 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 certifications in medical oncology and hematology 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 Makena 250 mg/ml IM weekly.According to Norwitz, a woman with a singleton gestation and a prior spontaneous preterm singleton birth should be offered progesterone supplementation starting at 1624 weeks of gestation, regardless of transvaginal ultrasound cervical length, to reduce the risk of recurrent spontaneous preterm birth. In a systematic review by Eke and colleagues, combination therapy of cerclage plus hydroxyprogesterone caproate, in patients with an ultrasound-indicated cerclage, was not associated with a reduction in spontaneous recurrent preterm birth or improvement in perinatal outcome versus cerclage alone. In this case, the patient does not have a history of a spontaneous preterm singleton birth. Additionally, the patient has an incompetent cervix and is treated with a cerclage. The medical literature does not support the use of the requested medication in addition to the placement of a cerclage in order to treat the patients medical condition. Therefore, the requested Makena 250 mg/ml IM weekly is not medically necessary for treatment of the patients medical condition.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 obstetrics and gynecology 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 celiac plexus block and two related office outpatient visits are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  The physician reviewer found that Ehlers-Danlos can be a debilitating disease with chronic pain in the joints and abdomen. The treatment of chronic abdominal pain in the setting of Ehlers-Danlos remains difficult. Thus, opioid sparing techniques, such as celiac plexus blocks, need to be considered early in the treatment algorithm even in cases of non-malignant chronic abdominal pain. Barbon and colleagues reported that celiac plexus blocks provided decreased pain in patients with Ehlers-Danlos syndrome and medial arcuate ligament syndrome. Given this support, the requested celiac plexus block and two related office outpatient visits are 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 celiac plexus block and two related office outpatient visits are 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 reviewers 1, 2 and 3 are board certified in anesthesiology with subspecialty certification in pain management and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for magnetic resonance imaging (MRI) of the brain sinuses without contrast. Chua and colleagues note that MRI is more specific than computed tomography (CT) in characterizing unilateral maxillary sinus opacification, with greater diagnostic certainty and reproducibility. The authors further note that the additive diagnostic value of MRI complements CT, potentially reducing diagnostic delays in some cases and the need for diagnostic endoscopic sinus surgery in others. Alves and colleagues note that CT and MRI are commonly used in evaluation of paranasal sinuses and that description of such findings by a radiologist can lead to a change in treatment strategy. In this case, the patient had a history of severe facial pain, perhaps due to a dental abscess, and underwent an MRI for evaluation. In this clinical setting, given the patients symptoms were of unknown etiology, the service at issue was medically indicated to aid in diagnosis and treatment strategy. Therefore, MRI of the brain sinuses without contrast was medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the services at issue was medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in otolaryngology 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.