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 Home infusions of Octagam 50 grams daily for three days, then 75 grams every four weeks thereafter. In the peer-reviewed medical literature, there is increasing evidence that immunomodulation with intravenous immunoglobulin (IVIG) is helpful in treating patients with autonomic dysfunction and Sjogrens disease. However, these studies are small and there is a lack of national guidelines to recommend this therapy. Scientists conducted a study evaluating IVIG in patients with autoimmune dysautonomias. The authors found increasing evidence that IVIG is safe and effective in a subset of patients with autonomic disorders and evidence for autoimmunity. Moreover, the authors noted that, Antiphospholipid antibodies and novel Sjogren antibodies are often present in these patients and correlate with a high response rate to IVIG. In this case, the patient has been treated with prednisone, Pamelor, Lyrica and Cosentyx for chronic inflammatory sensory polyneuropathy. The medical records provided do not demonstrate a diagnosis of Sjogrens or adequate documentation to support the diagnosis of peripheral neuropathy to support an indication for IVIG. For these reasons, the requested home infusions of Octagam 50 grams daily for three days, then 75 grams every four weeks thereafter 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 certifications in allergy and immunology and rheumatology 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 Otezla 30 mg tablets.  The American College of Rheumatology guidelines for the treatment of psoriatic arthritis recommend full dose prescription strength nonsteroidal anti-inflammatory drugs (NSAIDs) and physical therapy as the first line of treatment for either peripheral or axial psoriatic arthritis. Poddubnyy states, NSAIDs are highly effective against the major symptoms of axial spondyloarthritis (axSpA) (pain and stiffness) and may have disease-modifying properties including retarding progression of structural damage in the spine. Therefore, NSAIDs, unless contraindicated, are the treatment of choice for the majority of patients with axSpA. Beyond NSAIDs, only tumor necrosis factor (TNF) alpha blockers are effective and approved for the treatment of active axSpA. Several novel drugs (i.e. monoclonal antibodies targeting interleukin-17, interleukin-12/23, inhibitors of phosphodiesterase-4 and kinases), which might be effective in axSpA, are currently under investigation. Pharmacological therapy of axSpA should always be combined with nonpharmacological treatment including education and regular exercise/physiotherapy. In this case, the patient has been diagnosed with psoriatic arthritis. There is no documented trial with full dose prescription strength NSAIDs, and the records do not reflect a medical contraindication to NSAIDs. Therefore, Otezla 30 mg tablets are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty in rheumatology 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 parent of the patient has requested authorization and coverage for speech therapy services. The submitted documentation supports the medical necessity of the requested services. Speech therapy is standard of care for children with autism spectrum disorder. Hyman and colleagues stated, All children with autism spectrum disorder (ASD) should have documentation of specific coexisting speech and language diagnoses so that appropriate intervention might be provided. Speech-language therapy is the most commonly identified intervention provided for children with ASD. Researchers noted the importance of early intervention for children with autism spectrum disorder. Studies concluded that behavioral interventions were evidence based to induce speech among individuals with developmental disabilities. Scientists described treatment for autism spectrum disorder involving intensive behavioral therapy and educational programming along with traditional ancillary services, such as speech/language, occupational, and physical therapies. In this case, although the patients progress is slow, he continues to make progress. His providers recommend that speech therapy be continued. Therefore, speech therapy services are medically necessary for the 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 neurology with special qualification in child neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for tethered cord release surgery. Gao and colleagues found that surgical treatment on adult patients with tethered cord syndrome can improve the neurologic deficits which are associated with the course of disease, and early treatment has much better curative effect. In this case, given the patients diagnosis of symptomatic tethered cord syndrome, release of the filum terminale is medically indicated. Therefore, tethered cord syndrome is medically necessary for the evaluation 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 neurological 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 reimbursement for FoundationOne CDx comprehensive genomic profiling test. Genetic or mutational testing is informative for patients with metastatic colorectal cancer since it can help direct therapeutic decisions. Knowledge of tumor mutations figures prominently in the work-up of metastatic colon cancer in the NCCN guidelines. Specifically, KRAS and BRAF mutations may inform therapy decisions. KRAS is one of the most frequently mutated oncogenes in colorectal cancer. A mutation in KRAS has been associated with worse progression-free survival (PFS) compared to patients with wild type KRAS when treated with monoclonal antibody directed against epidermal growth factor receptor (EGFR) in combination with chemotherapy. There is published data from a large retrospective trial that the presence of the BRAF mutation provides additional prognostic information with regard to cetuximab treatment. The MEK kinases are within the same pathway as RAS and BRAF. This provides evidence that treatment with dabrafenib, trametinib, or vemurafenib to tumors with constitutive RAS signaling may be effective. One study on 86 patients reported PFS on regimen selected by molecular profiling was compared to PFS on the last chemotherapy regimen. The regimen selected by molecular profiling offered a 27% survival advantage. In summary, there are multiple gene mutations with both prognostic and therapeutic utility making the testing reasonable for this patient with a diagnosis of moderately differentiated adenocarcinoma of the colon with extension to the serosal margin. Therefore, the FoundationOne CDx comprehensive genomic profiling test 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 FoundationOne CDx comprehensive genomic profiling test 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 certifications in medical oncology and hematology 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 certification in medical oncology 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 authorization and coverage for monthly home infusions of Privigen 10% dosed at 2 grams/kg over five days for initial dose, followed by 1 gram/kg over two days thereafter. Standard treatment of small fiber neuropathy is dependent on the underlying etiology as well as treatment of associated neuropathic pain, which can include several different classes of medications (Hovaguimian and Gibbons). Small fiber polyneuropathy has various underlying causes, including associations with systemic autoimmune conditions. In small fiber neuropathy, current neuropathic pain treatment options are generally insufficient to control the pain. Intravenous immunoglobulin (IVIG) is a first-line treatment for immune-mediated neuropathies such as Guillain-Barre syndrome, chronic inflammatory demyelinating polyneuropathy, and multifocal motor neuropathy. IVIG has been shown to have significant efficacy in the treatment of patients with disabling autoimmune forms of dysautonomia, which are oftentimes small fiber polyneuropathies. Researchers provided Class IV evidence that IVIG is safe and effective for rigorously selected small fiber polyneuropathy patients with evidence to suggest an autoimmune causality. In this case, the patient has small fiber neuropathy and a history of autoimmunity. Her symptoms have not been controlled with conventional medical therapy. Based on the current medical studies, patients with autoimmune small fiber neuropathy are likely to improve clinically with IVIG. Given this support, the requested monthly home infusions of Privigen 10% dosed at 2 grams/kg over five days for initial dose, followed by 1 gram/kg over two days thereafter 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 monthly home infusions of Privigen 10% dosed at 2 grams/kg over five days for initial dose, followed by 1 gram/kg over two days thereafter 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 medication is 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 authorization and coverage for right sacroiliac (SI) joint fusion surgery (CPT 27279). The International Society for Advancement of Spine Surgery (ISASS) provided criteria for sacroiliac (SI) joint fusion (Lorio, et al.). The requirements include significant SI joint pain confirmed by at least three positive SI joint provocative tests, confirmation of the SI joint as a pain generator with at least 75% decrease in pain following fluoroscopically guided diagnostic intra-articular SI joint block in the immediate post-injection period, and failure to respond to at least six months of non-surgical treatment. The ISASS noted that additional or alternative diagnoses that could be responsible for the patients ongoing pain or disability should be evaluated and ruled-out. Based on the records provided for review, this patient presents with persistent pain over the right SI joint with chronic SI joint dysfunction. She reports that her pain is worse with walking, sitting, standing, and laying down. The patient has also experienced balance issues due to leg weakness. Clinical examination findings included four positive provocative tests and a positive Fortins finger sign. Diagnostic and therapeutic SI joint injections reportedly produced 80% of pain relief. The provider documented that the patient has failed conservative treatment consisting of physical therapy, activity modification, medications, and injections. There is reported imaging evidence of SI joint degeneration and no concurrent lumbar spine pathology. Current-evidence based medical literature supports minimally invasive SI joint fusion for patients with SI joint dysfunction due to degenerative sacroiliitis or SI joint disruption. Duhon and colleagues reported strong evidence that minimally invasive SI joint fusion using triangular porous coated implants placed across the SI joint improved pain, disability and quality of life at 24 months in patients with SI joint dysfunction due to degenerative sacroiliitis and SI joint disruption. Therefore, the requested right SI joint fusion (CPT 27279) 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 right SI joint fusion (CPT 27279) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician 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: The patient has requested authorization and coverage for esketamine (Spravato) nasal spray. This patient carries a documented diagnosis of major depressive disorder, recurrent severe, without psychosis. Moreover, the patient meets the definition of treatment resistant major depressive disorder due to failure of medical therapies including high-dose Paxil 40 mg and Lexapro. He has also had multiple trials of sufficient duration with Wellbutrin. Currently, he is on Viibryd 40 mg daily in addition to Wellbutrin XL 300 mg daily and BuSpar 5 mg three times a day. He is currently on the maximum dose of Viibryd, and has undergone a sufficient trial of medication and Wellbutrin. Wellbutrin should not be further increased due to its influence via 2D6 on Viibryd levels, which could elevate his risk of serotonin syndrome, especially since he is also on a stimulant and BuSpar. The patient reports that his depression has worsened over the past year and he is unable to get out of bed. The patients depressive symptoms are causing him extreme distress and his occupational functioning is now severe. Researchers noted that a variety of antidepressant treatments are available for the treatment of major depressive disorder, but may patients fail to achieve sustained symptomatic remission. Authors concluded that the results of their study consistently showed a clinically relevant, favorable improvement in depressive symptoms with esketamine (either 56 mg or 84 mg) nasal spray plus a newly initiated antidepressant. On review of the medical literature and this patients clinical history, the patient meets the criteria for treatment resistant depression. His clinical condition is severe and the rapid benefits of Spravato in alleviating his depression is appropriate. All told, the requested Esketamine (Spravato) nasal spray is medically necessary for 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) Chantix 0.5 mg tablet, and (2) Chantix 1 mg tablet. Mills and colleagues compared the efficacy of nicotine replacement and varenicline (Chantix), and found that all therapies were effective in smoking cessation. Only varenicline demonstrated benefit over standard nicotine replacement therapy. In this case, the patient is a documented long-term smoker who would benefit from smoking cessation therapy. Chantix is medically appropriate in this patients case. Therefore Chantix 0.5 mg tablet, and (2) Chantix 1 mg tablet are 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 family 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: An enrollee has requested authorization and coverage for Rinvoq ER 15mg tablets.The requested medication, Rinvoq, is a JAK inhibitor that is similar to Xeljanz (tofacitinib) for the treatment of rheumatoid arthritis. 2015 American College of Rheumatology (ACR) guidelines for the treatment of rheumatoid arthritis recommend methotrexate (MTX) +/- a TNF inhibitor (TNFi) as the next treatment in those who have failed methotrexate alone. There are also multiple studies demonstrating efficacy and safety with TNFi over the years in treating moderate to severe rheumatoid arthritis. There is evidence that a 2nd TNFi is effective in those who have tried and failed a previous TNFi or for those who have had adverse reactions to other TNFi. There is also newer literature that demonstrates that tofacitinib and methotrexate combination therapy was non-inferior to adalimumab and methotrexate combination therapy in the treatment of rheumatoid arthritis in patients with an inadequate response to methotrexate. Another study demonstrates that tofacitinib is helpful in biologic naive and biologic non-responders. Although it is not inferior to Humira and is efficacious in previous biologic non-responders, the current guidelines continue to recommend a 2nd TNFi over a JAK inhibitor. In this case, however, the patient has a contraindication due to her end stage renal disease and pulmonary fibrosis. Under these circumstances, a JAK inhibitor would be preferred due to its better safety profile. Accordingly, the requested medication, Rinvoq ER 15mg tablets, is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary to treat the patient's medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine, with subspecialty certification in rheumatology, 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.