Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested reimbursement for injections of platelet-rich plasma (PRP) provided on 11/06/20, 5/12/21, 6/10/21, and 7/15/21.Findings: Two out of three physician reviewers found that injections of PRP provided on 11/06/20, 5/12/21, 6/10/21, and 7/15/21 were not likely to have been more beneficial for you than any available standard therapy.Mao and colleagues state, Most studies suggest that subcutaneous injection of PRP is likely to reduce hair loss, increase hair diameter and density in patients with androgenic alopecia. Because of the low quality of the studies, small sample sizes, different treatment regimens and possible publication bias, the results of this meta-analysis should be interpreted with caution. Furthermore, more randomized controlled studies should be performed. Hesseler and Shyam advocated the use of PRP for alopecia. However, they noted further studies were needed to provide reproducibility and standardization. They concluded, This review advocates for the use of PRP in three to four monthly sessions for the treatment of alopecia. Further, Gupta and colleagues concluded that based on the available studies, it is difficult to determine the efficacy of PRP in scarring alopecia conditions. While platelet-rich plasma does hold some promise in the use of alopecia, further well-designed studies are needed to confirm a benefit and establish standardized treatment protocols for the preparation, timing and execution of the injections. In this case, the nature of the patient's diagnosis is unclear based on the submitted records. Additionally, the patient was noted to have normal scalp hair distribution and texture on 10/02/20. Based on the medical literature, more studies are needed to establish the benefit from PRP treatment. Therefore, injections of PRP provided on 11/06/20, 5/12/21, 6/10/21, and 7/15/21 were not likely to have been more beneficial for treatment of the patients condition than any available standard therapy. Final Result: The reviewers determined that the services at issue were not likely to have been more beneficial than any available standard treatment for the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer 1, reviewer 2, and reviewer 3 are board certified in plastic surgery. All reviewers 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 Synvisc-One (hyaluronan) injection 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 patients case, prior viscosupplementation was beneficial. Furthermore, the patients options are limited. The alternative is total knee arthroplasties of both knees. Therefore, Synvisc-One (hyaluronan) injection in both knees is medically necessary for treatment of the patients medical condition.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:  An enrollee has requested authorization and coverage for Gardasil series (HPV vaccine).The Centers for Disease Control and Prevention (CDC) guidance recommends the HPV vaccine for individuals of both sexes up until the age of 26. At greater ages, a decision should be based on a discussion between the patient and the physician. As a patient ages, the probability of becoming infected with HPV increases, and the vaccine may be less effective. Importantly, the CDC does not recommend the vaccine for individuals who are older than 45 years of age. Therefore, this request falls outside of the CDC recommendations. Therefore, the requested Gardasil series (HPV vaccine) is not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested vaccine 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 certification in infectious disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Intracept procedure (HCPCS C9752). A review of the recent medical literature reveals that the Intracept procedure is a safe and effective treatment modality for patients with chronic vertebrogenic pain. In this patients case, there is evidence of vertebrogenic pain caused by vertebral endplate degeneration with cortical bone damage and subchondral bone inflammatory reaction and edema at the L5-S1 level. Vertebrogenic pain is often the cause of low back pain transmitted by the basivertebral nerve. As noted in the medical literature, radiofrequency ablation of the basivertebral nerve can lead to a thermal injury of nerve tissue and relief of pain (De Vivo, et al.). Khalil and colleagues concluded that minimally invasive radiofrequency ablation of the basivertebral nerve led to significant improvement of functional and pain relief at three-month follow-up in patients with chronic low back pain. This patients low back pain has failed to improve with adequate non-invasive treatment including physical therapy and medications, as well as injection therapy. The patients low back pain is interfering with his ability to perform activities of daily living. In addition, the patient has declined invasive surgery with the exception of minimally invasive procedures. In light of the foregoing, the requested Intracept procedure (HCPCS C9752) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested Intracept procedure (HCPCS C9752) 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 reviewer 1 is board certified in orthopedic surgery and is actively practicing. Physician reviewer 2 is board certified in orthopedic surgery and is actively practicing. Physician reviewer 3 is board certified in orthopedic surgery 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

Findings:  The physician reviewer found that An enrollee has requested authorization and coverage for lymph vein bridging anastomosis (lymphovenous bypass - CPT codes 38999, 38790, and 35226). The records document that this patient presents with progressive right upper extremity lymphedema secondary to breast cancer diagnosis and treatment. The patients provider has recommended treatment with lymph vein bridging anastomosis. Lymphaticovenular anastomosis for this patients arm edema is clinically appropriate and generally accepted as a potentially curative treatment for lymphedema. The patient is most likely to benefit from treatment before she develops progressive fibrosis that occurs with untreated chronic lymphedema. Winters and colleagues found that treatment with lymphaticovenular anastomosis is effective in reducing arm volume difference in patients suffering from breast cancer-related lymphedema. Cornelissen and colleagues concluded that lymphaticovenular anastomosis for early-stage breast cancer-related lymphedema resulted in a significant improvement in quality of life and a high rate in stocking discontinuation. Forte and colleagues reported that the maintained effectiveness of this treatment modality in long-term follow-up suggests great efficacy. Given this support, the requested lymph vein bridging anastomosis (lymphovenous bypass - CPT codes 38999, 38790, and 35226) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the requested lymph vein bridging anastomosis (lymphovenous bypass - CPT codes 38999, 38790, and 35226) 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: An enrollee has requested authorization and coverage for Synvisc-One (hyaluronan) injection 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 patients options are limited. The patient has tried physical therapy and multiple corticosteroid treatments, with limited relief. The patients alternative is bilateral total knee arthroplasties for mild osteoarthritis of both knees. Therefore, Synvisc-One (hyaluronan) injection in both knees is medically necessary for treatment of the patients medical condition.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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Forteo for two years continuous treatment. The records provided for review document that this patient has a history of severe osteoporosis on dual energy x-ray absorptiometry (DEXA) report with a T-score of -3.6 in the left femoral neck. The patients provider has recommended treatment with Forteo. Historically, bisphosphonates have been considered the first-line treatment option for the management of patients with osteoporosis. However, numerous new treatments have become available in recent years, including Forteo. Researchers conducted a meta-analysis to compare the efficacy of Forteo and bisphosphonates for reducing vertebral fracture risk and bone mineral density (BMD) in lumbar spine and femoral neck in postmenopausal women with osteoporosis. The authors found that Forteo has been shown that directly promote bone formation and thereby reduce the attendant risk of fractures. Moreover, the U.S. Food and Drug Administration (FDA) has approved Forteo for the treatment of osteoporosis in postmenopausal women at high risk for fracture. Given this patients extremely low BMD and history of fracture, she is a good candidate for therapy with Forteo. Given these findings, the requested Forteo for two years continuous treatment 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 diabetes, endocrinology, 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 authorization and coverage for Actemra (subcutaneous). The National Comprehensive Cancer Network (NCCN) has published extensive analysis on the management of immunotherapy related toxicities. Medical literature note that some immunotherapies are associated with unique toxicities of cytokine release syndrome (CRS) and neurologic toxicity and that the assessment and grading of these toxicities vary considerably across clinical trials and across institutions, making it difficult to compare the safety of different products and hindering the ability to develop optimal strategies for management of these toxicities. Medical literature note that tocilizumab may be a therapeutic option for the management of steroid refractory immune related adverse events secondary to immune checkpoint blockade. In this case, the patient has been diagnosed with CRS secondary to dual immune checkpoint blockade. In this clinical setting, while the NCCN guidelines support the use of intravenous tocilizumab, the use of subcutaneous tocilizumab is not discussed. Therefore, intravenous Actemra is medically necessary for the treatment of this patient.Final Result: The reviewer determined that a portion of the requested medication 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 internal medicine with sub-specialty certifications in medical oncology and in 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for Orencia 125 mg/mL injection pen.According to the 2021 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis, the addition of biologic disease-modifying antirheumatic drugs (DMARDs) (i.e., Orencia) or targeted synthetic DMARDs (i.e., Kevzara or Xeljanz) is recommended when escalating therapy to optimize rheumatoid arthritis disease control. The guideline also indicates that there is no recommendation for a targeted synthetic DMARD over a biologic DMARD. Either drug class is an acceptable next-line agent when escalating therapy to optimize disease control. In this case, the patient still has disease activity despite being on maximum methotrexate. There is sufficient support for the requested medication in this clinical setting. Therefore, Orencia 125 mg/mL injection pen is medically necessary for 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 internal medicine with sub-specialty 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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Smartpill procedure (CPT 91112, gastrointestinal transit and pressure measurement, stomach through the colon, wireless capsule, with interpretation and report). Findings:  The physician reviewer found that his patient presented with complaints of constipation, fecal incontinence, urgency, and a history of Parkinsons disease. The current peer-reviewed medical literature does not recommend use of the Smartpill for evaluation of symptoms such as constipation, fecal incontinence, and urgency. The Agency for Healthcare Research and Quality (AHRQ) conducted a systematic review on the effectiveness of the Smartpill compared with other available tests for the evaluation of gastric and colonic motility. The AHRQ found that the strength of evidence regarding the ability of Smartpill to detect slow-transit constipation was low. Similar findings have been reported in the medical literature (Lembo, et al.). This use of Smartpill has also been evaluated in studies in patients with Parkinsons disease. However, there is a paucity of peer-reviewed medical literature demonstrating improved patient health outcomes with use of the Smartpill in the management of constipation, fecal incontinence, or urgency in patients with Parkinsons disease. All told, the Smartpill procedure (CPT 91112, gastrointestinal transit and pressure measurement, stomach through the colon, wireless capsule, with interpretation and report) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.   Findings: Two of the three physician reviewers found the Smartpill procedure (CPT 91112, gastrointestinal transit and pressure measurement, stomach through the colon, wireless capsule, with interpretation and report) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for 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 internal medicine with subspecialty certification in gastroenterology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in gastroenterology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certification in gastroenterology 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:  An enrollee has requested authorization and coverage for custom orthotics.Medical literature shows, Studies have shown that orthotics, both prefabricated and custom fitted, reduce pain and improve function in adults with acute plantar fasciitis with few risks or side effects. Used alone or in addition to conventional therapy (NSAIDs, stretching, lifestyle modification), orthotics are effective and well-tolerated by patients for short-term pain relief and improved function. Custom orthotics are utilized to control the abnormal biomechanics of a foot, thereby alleviating abnormal pressures that ultimately cause pain. In this case, the patient has severe over pronation, metatarsalgia, plantar fasciitis, and posterior tibial tendon insufficiency. The provider has recommended custom orthotics to help stop over pronation and allow for offloading of the plantar fascia and the metatarsals. There is sufficient support for the requested equipment in this clinical setting. Therefore, custom orthotics are medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested equipment 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 podiatrist 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.