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 Dupixent 300 mg/2 mL (initial dose of 600 mg followed by 300 mg given every other week).The treatment of atopic eczema involves the use of nonpharmacologic interventions like emollients. The next step would be topical interventions like topical corticosteroids. For patients with widespread disease not controlled by topical agents, systemic treatment is indicated. Dupixent is recommended for patients when topical treatment is not sufficient. Dupixent has been approved by the U.S. Food and Drug Administration and has been demonstrated to be safe and effective for atopic eczema. Medical literature state, Dupilumab is also an option for patients who are not candidates for or failed previous treatment with conventional immunosuppressive agents. [] Compared with conventional immunosuppressive agents, dupilumab has a favorable safety profile and may be used for long-term treatment of atopic dermatitis. In this case, the patient has tried and failed alternative therapies, such as topical corticosteroids, immunosuppressive drugs, and phototherapy. Therefore, Dupixent 300 mg/2 mL (initial dose of 600 mg followed by 300 mg given every other week) is medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the 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:  An enrollee has requested authorization and coverage for Xifaxin. Findings: Xifaxan has proven to be effective for the treatment of irritable bowel syndrome, diarrhea-predominant (IBS-D). The U.S. Food and Drug Administration (FDA) has approved Xifaxan for the treatment of IBS-D, and the medication has been demonstrated to be safe and effective in randomized placebo-controlled trials. In a study, Xifaxan was demonstrated to be effective, with significant symptom improvement in irritable bowel syndrome. The American College of Gastroenterology guidelines for the treatment of irritable bowel syndrome state that rifaximin (Xifaxan) is effective in the treatment of IBS-D. In this case, the patient has been diagnosed with irritable bowel syndrome with diarrhea. Additionally, the patient has previously had good control with Xifaxan. However, the dose requested is not supported. Clinical trials and the FDA approval for Xifaxan in the treatment of IBS-D support the use of Xifaxan 550 mg three times daily for 14 days, with up to two additional courses at least 10 weeks apart. Therefore, Xifaxin 550 mg (#60 tablets/30 day supply for ongoing treatment) is not medically necessary for the 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 sub-specialty certification in 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for sacroiliac (SI) joint surgery.Findings: Two out of three physician reviewers found that the SI joint surgery is likely to be more beneficial for you than any available standard therapy.SI joint syndrome is one common reason for persistent chronic low back pain. If conservative treatments fail to improve symptoms, arthrodesis surgery can be considered. Minimally invasive approaches have recently emerged, providing a better alternative to conventional methods. A triangular implant system can be used without need for bone grafting or screw fixation to achieve an optimal fusion of the SI joint. Minimally invasive surgical arthrodesis of the SI joint is known to result in significant improvement in pain and function. Moreover, a study by Rainov and colleagues found that, SI joint fusion with triangular titanium implants produces significant improvement in pain and disability related to SI joint dysfunction. In this case, the patients right SI joint is known to be the source of pain. This was confirmed with two SI joint injections with associated excellent short-term pain relief. Additionally, the patient has failed conservative treatment. Therefore, the requested SI joint surgery is likely to be more beneficial for treatment of the patients condition than any available standard therapy. Final Result: The reviewers determined that the requested service is likely to be more beneficial than any available standard treatment for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer 1, reviewer 2, and reviewer 3 are board certified in orthopedic 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for vitamin D testing (CPT code 82306), performed by Presence Healthcare Services. LeBlanc and colleagues note that vitamin D deficiency has been associated with adverse health outcomes. The clinical manifestations of vitamin D deficiency depend upon the severity and duration of the deficiency. While the majority of patients with moderate-to-mild vitamin D deficiency are asymptomatic, severe Vitamin D deficiency results in hypocalcemia, leading to bone disorders. Rockwell and colleagues note that in the clinical management of low vitamin D, there is no clear evidence supporting vitamin D screening to improve health outcomes, and that population-wide vitamin D screening in community-dwelling adults who are asymptomatic or at low risk of low vitamin D is not recommended. Forrest and colleagues note that patient groups with higher rates of vitamin D deficiency included those who were non-white, obese, in poor health, having low high-density lipoprotein cholesterol, and having hypertension. Others at risk for vitamin D insufficiency may include those taking medications that accelerate the metabolism of vitamin D, hospitalized or institutionalized patients, people with limited sun exposure, and those  with osteoporosis or malabsorption, including inflammatory bowel disease and celiac disease. While vitamin D testing may be appropriate for patients at high risk for vitamin D deficiency, in this case, the submitted medical records did not note that the patient had any chronic medical conditions that would put him at risk for vitamin D deficiency. Given that vitamin D screening is not recommended for the general population, the service at issue was not medically indicated. Therefore, vitamin D testing (CPT code 82306), performed Presence Healthcare Services, was not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the service at issue 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 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 Praluent (alirocumab) injections 75 mg/mL every two weeks. Findings:  The physician reviewer found that either ezetimibe or a proprotein convertase subtilisin-kexin type 9 (PCSK9) may be added to maximally tolerated statin therapy in patients with clinical ASCVD with comorbidities and baseline LDL-C over 70 mg/dL. The authors further note that considerations that may favor the initial choice of ezetimibe include patients who require less than 25% additional lowering of LDL-C, ease of use as an oral agent with low pill burden, patient preferences, and hypertension. In this case, the patient is noted to have persistent elevated liver enzymes. In this clinical setting, given that ezetimibe may worsen liver function, the requested medication is medically indicated. Therefore, Praluent (alirocumab) injections 75 mg/mL every two weeks 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 internal medicine withs sub-specialty certifications in cardiovascular disease and in clinical cardiac electrophysiology 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 Euflexxa injection series to the right knee (weekly for three weeks).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 a history of benefit from prior viscosupplementation. Furthermore, the patients options are limited. The patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. Therefore, Euflexxa injection series to the right knee (weekly for three weeks) is medically necessary for 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:  An enrollee has requested authorization and coverage for Orencia.Findings: 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., Rinvoq 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 has tried and failed conservative therapy with minocycline and hydroxychloroquine. Therefore, Orencia is medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the 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: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has requested authorization and coverage for Xifaxan 550 mg (three times a day for 14 days). In this case, the patient has a diagnosis of irritable bowel syndrome (IBS) with diarrhea. Pimental and colleagues note that among patients who had IBS without constipation, treatment with rifaximin (brand name Xifaxan) for two weeks provided significant relief of IBS symptoms, bloating, abdominal pain, and loose or watery stools. Lembo and colleagues note that in a phase 3 study of patients with relapsing symptoms of IBS with diarrhea, repeat rifaximin treatment was efficacious and well tolerated. The American College of Gastroenterology recommends the use of rifaximin for reduction in global IBS symptoms, as well as bloating in non-constipated IBS patients. In this clinical setting, current medical literature supports the use of the requested medication. Therefore, Xifaxan 550 mg (three times a day for 14 days) 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 internal medicine with sub-specialty certification in 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral tonsillectomy (CPT code 42826). The records provided for review document that this patient has recurrent tonsilloliths and halitosis with complaint of chronic throat pain. The provider noted that the patient has failed conservative management with digital removal and regular use of a Water Pik. Based on the patients continued symptoms, the provider has recommended bilateral tonsillectomy. As noted in the medical literature, tonsilloliths are recurrent problems due to the crypts in tonsils. In this clinical setting, when a patient fails conservative management, the recommended treatment is a tonsillectomy (Arvisais-Anhalt, et al.). Since this patients symptoms have not improved with conservative therapy, the requested tonsillectomy is appropriate. Given these findings, the requested bilateral tonsillectomy (CPT code 42826) 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for an infliximab (Remicade) anti-body level test (laboratory procedure #80230 and #82542).Findings:  Two of the three physician reviewers found the infliximab (Remicade) anti-body level test (laboratory procedure #80230 and #82542) was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy. The service at issue is a quantitative monitoring assay designed to measure infliximab and antibodies to infliximab levels, intended to provide insight into factors contributing to a patient's loss of response and to guide treatment decisions. There is insufficient evidence in current medical literature to determine the role of measurement of antibodies to infliximab and how the use of the test results in improved health outcomes compared to other accepted diagnostic tests. Lee and colleagues note in a meta-analysis that the presence or absence of anti-infliximab antibodies did not affect the rates of clinical remission and that the prevalence of anti-infliximab antibodies depended on the regimen of infliximab administration and the use of immunosuppressants. The authors further noted that patients who tested positive for anti-infliximab antibodies were at an increased risk of infusion reactions but had similar rates of remission compared with patients who tested negative for anti-infliximab antibodies. The authors concluded that further analysis is required to determine whether loss of response is dependent on the titre of anti-infliximab antibodies. In this case, given that visit notes reported that the patient was in remission, results from the service at issue would not have changed the management of his treatment regimen as dose escalation would not have been indicated in this clinical setting. Therefore, the infliximab (Remicade) anti-body level test (laboratory procedure #80230 and #82542) was 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 service at issue was 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 internal medicine with sub-specialty certification in gastroenterology 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 Supartz injections in both knees (HCPCS J7321).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 and failed other conservative treatments, including frequent corticosteroid injections, with the alternative being bilateral total knee arthroplasties. Therefore, Supartz injections in both knees (HCPCS J7321) are medically necessary for 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 Synvisc One injection in the left knee. Findings:  The physician reviewer found that  records provided for review document that this patient presents with a history of osteoarthritis of the left knee with associated chronic pain. She has failed treatment with arthroscopic surgery, and corticosteroid injections. The patient experienced excellent results from viscosupplementation with Synvisc One in the past. The provider has recommended a repeat Synvisc One injection for the left 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, the patient has tried and failed other conservative treatments with the alternative being a total knee arthroplasty. Therefore, the requested Synvisc One injection in the left knee 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.