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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for inpatient intensive care unit (ICU) services. The records provided for review document that this patient presented with a head injury in good neurological condition. However, the patients computed tomography (CT) scan demonstrated a 0.6 cm subdural hematoma in the middle cranial fossa, scatter traumatic subarachnoid hemorrhage, and a frontal contusion. On the basis of the description of the patients presentation and imaging findings, her admission to the hospital and ICU was consistent with current medical recommendations and peer-reviewed literature. The patient required a period of careful observation and repeat imaging. Careful blood pressure control with careful titration of IV medication was indicated in the context of the patients intraparenchymal hemorrhage. Safe and adequate titration in this clinical setting cannot be performed on a floor status patient or for any meaningful period of time in the emergency department. Overall, the records support that a severe problem existed and there was an imminent need for surgery. The patient had a complex intracranial hemorrhage with a subdural, traumatic subarachnoid hemorrhage. Although the patient was in good clinical condition neurologically, careful ongoing evaluation during the first day or so after this type of injury is critical to ensure that there was no progression and a need for immediate medical intervention. The current medical literature supports that subdural hematomas, even small ones, and traumatic intraparenchymal hemorrhages can progress substantially and require surgical care. As such, hourly neurological checks are required to identify neurological decline and aid in rapid and appropriate decision making. For these reasons, the inpatient services provided were medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were 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 authorization and coverage for anthralin 1% cream. Researchers note that data on treatment options in pediatric alopecia areata are limited, and that prior results on the efficacy of anthralin in children with alopecia areata have been mixed. However, the authors noted that based on a retrospective study of 37 patients started on topical anthralin before age 17, topical anthralin provided the potential for significant scalp regrowth with minimal systemic effects. In this case, the patient presents with a history of alopecia universalis and has failed several standard therapies such as topical steroids, minoxidil, and squaric acid. There is a lack of evidence supporting the use of other standard therapies, which may be associated with side effects, Janis kinase (JAK) inhibitors in children, or systemic therapies, which may carry an unfavorable risk/benefit profile for children, over the requested medication. Therefore, anthralin 1% cream is likely to be more beneficial for treatment of the patients condition than any available standard therapy. Findings:  Three of the three physician reviewers found the requested for anthralin 1% cream 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 medication is 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 dermatology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for risdiplam. Mercuri and colleagues describe spinal muscular atrophy (SMA) as an autosomal recessive disorder characterized by degeneration of motor neurons in the spinal cord and caused by mutations of the survival of motor neuron 1 gene (SMN1). Messina and Sframeli note that nusinersen (brand name Spinraza), an antisense oligonucleotide, may be used to treat SMA. Dhillon reports that risdiplam is approved by the U.S. Food and Drug Administration (FDA) for the treatment of SMA. While risdiplam is given orally, nusinersen is administered intrathecally, and both medications are modulators of SMN2 splicing. In this case, the patient has advanced SMA type 1 and has shown no improvement since starting treatment with Spinraza, a SMN2 splicing modulator drug with the same action mechanism as the requested medication. Given the advanced stage of the patients disease and lack of clinical, objective improvement following three years of treatment with Spinraza, the requested medication is not medically indicated. Therefore, risdiplam is 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 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: An enrollee has requested authorization and coverage for Euflexxa injections in the left knee.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, with the alternative being a total knee arthroplasty in the presence of mild osteoarthritis of the left knee. Therefore, Euflexxa injections for the left knee 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for consultation with a provider who offers nonoperative regenerative treatment options. In this case, the patient is being treated for osteoarthritis and torn cartilage in the right hip. Progress notes on March of 2021 report moderate persistent bilateral hip pain that interferes with activities of daily living such as walking and hiking. The patient has requested consultation with a provider who specializes in nonoperative regenerative treatment options. Current evidence-based peer-reviewed literature supports decision aids in the orthopedic treatment of patients, utilizing appropriate levels of care for initial evaluation and treatment. Researchers  found that When used in routine care, decision aids are associated with increased knowledge, more shared decision-making, and lower surgical rates. However, there is a lack of adequate data showing improved long-term patient health outcomes with the use of regenerative medicine for the treatment of patients with joint conditions. For these reasons, the requested consultation with a provider who offers nonoperative regenerative treatment options is 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 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 me
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Saxenda 3 mg/0.5 mL. Findings:  The physician reviewer found that diet, physical activity, and behavioral modifications are the cornerstones of weight management, weight loss achieved by lifestyle modifications alone is often limited and difficult to maintain. Pharmacotherapy for obesity can be considered if patients have a BMI of 30 kg/m2 or greater or BMI of 27 kg/m2 or greater with weight-related comorbidities. The Endocrine Society guidelines recommend that diet, exercise, and behavioral modifications are included in all obesity management approaches. Other tools, such as weight loss medications and bariatric surgery, can be combined with behavioral changes to reduce food intake and increase physical activity. Patients who have been unable to successfully lose weight and maintain a goal weight may be candidates for prescription medication. If a patient responds well to a weight loss medication and loses 5 percent or more of their body weight after three months, the medication should be continued. As body weight reduction is the main modifiable risk factor for polycystic ovary syndrome, therapeutic approaches in overweight or obese women with polycystic ovary syndrome have been developed. Saxenda (liraglutide) is a glucagon-like peptide-1 receptor agonist that promotes sustained weight loss, as well as abdominal fat reduction, in individuals with obesity, prediabetes, and type 2 diabetes mellitus. The majority of current clinical studies have demonstrated that liraglutide therapy achieved significant reductions in body weight, body mass index, and abdominal circumference in overweight and obese women with polycystic ovary syndrome. This patient has a history of obesity as determined by her BMI, which was 32.08 kg/m2 on 7/02/20. She has comorbidities including PCOS and hypertriglyceridemia. The patient has attempted to lose weight through lifestyle modification such as caloric restriction, exercise, and behavioral changes. The submitted documentation shows that the patient was treated with liraglutide (Saxenda) 3 mg with a good response and weight loss. Therefore, Saxenda 3 mg/0.5 mL 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 endocrinology, diabetes and metabolism, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an LED light kit (K0108) for the authorized power wheelchair.At issue in this case is whether the requested durable medical equipment (DME) accessory, an  LED light kit (K0108) for the authorized power wheelchair, is medically necessary for the patient to perform one or more mobility-related activities of daily living or instrumental activities of daily living in or out of the home, including access to the community.Optimizing lighting, whether through ambient environmental adaptations or via lighting equipment on a wheelchair is advisable as a general measure towards accident and injury prevention. This measure, however, addresses environmental concerns and falls outside of the medical necessity standard. Thus, a LED light kit is not medically necessary for the patient to perform one or more mobility-related activities of daily living or instrumental activities of daily living in or out of the home, including access to the community.Final Result: The reviewer determined that the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a Decipher prostate test. Findings:  The physician reviewer found that  In this case, a prostate pathology report dated reported a prostate-specific antigen (PSA) level of 5.5 ng/mL, multifocal Gleason 3+3 disease, and high-grade prostate intraepithelial neoplasia (PIN). While the Decipher prostate test may not be indicated for all patients with equivocal prostate pathology results and elevated PSA, it is specifically designed for this diagnostic situation. In this clinical setting, management options included a saturation biopsy or adding genomic information to guide therapy in the face of the patients multifocal disease process.  Therefore, the Decipher prostate test was likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the Decipher prostate test at issue was likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was likely to have been 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 urology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Edarbyclor (azilsartan-chlorthalidone). The records provided for review document that this patient has been treated with multiple medications for hypertension in the past. Aside from Edarbyclor, there is no report of treatment with any other angiotensin-receptor blocker (ARB) and thiazide combinations. Although the provider reported that Edarbyclor has managed the patients blood pressure, similar combinations on the Health Plans formulary with equivalent safety and efficacy are available for management of this patients condition. There is a lack of hypertension guidelines recommending one ARB medication over another for the management of isolated hypertension in the absence of heart failure or renal conditions. Although Edarbyclor is the only combination ARB and chlorthalidone medication available, there are similar alternative combinations using hydrochlorothiazide as the thiazide component that have been shown to provide a similar effect. Given these findings, the requested Edarbyclor (azilsartan-chlorthalidone) is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in cardiovascular 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Tymlos. Findings:  The physician reviewer found that guidelines, patients with a fracture within the past year or while on approved osteoporosis therapy, a very low T-score defined as less than -3.0, or at high risk for falls or history of injurious falls with high fracture probability, are candidates for treatment of osteoporosis. This guideline also states that Tymlos should be considered for patients unable to use oral therapy and as initial therapy for patients at very high fracture risk. In this case, the patient has a history of multiple stress fractures in both feet as a result of osteoporosis. Therefore, she is considered a person with a very high fracture risk. According to the guideline, patients at very high risk for fracture can receive Tymlos as initial therapy for the treatment of osteoporosis. In addition, this patient is a poor candidate for oral bisphosphonate therapy due to significant reflux disease and Tymlos is appropriate in patients unable to use oral therapies. Given these findings, the requested Tymlos 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 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 authorization and coverage for platelet-rich plasma (PRP) injections for the right knee. The records provided for review document that this patient sustained right knee internal derangement. Imaging revealed posterior horn medial meniscus with displaced meniscal tissue adjacent to the medial tibial spine, moderate chondromalacia patella with areas of subchondral bone marrow edema and cystic change, and large knee joint effusion. Treatment has included non-steroidal anti-inflammatory drugs (NSAIDs), physical therapy, and platelet-rich plasma (PRP) injections. The patient reported improved pain with PRP injections. The provider has recommended additional PRP injections. In the medical literature, researchers concluded that there are some data supporting PRP for well-selected patients in the treatment of osteoarthritis, ligament, tendon, and meniscal injuries of the knee. However, there is a paucity of evidence from prospective randomized controlled trials supporting the long-term safety and efficacy of PRP over standard available therapies for use in this clinical setting. Researchers concluded that there are a limited number of high-quality studies comparing outcomes and healing rates between patients undergoing meniscal repair with versus without PRP augmentation. Based on the available evidence, patients undergoing meniscal repair with PRP experience similar clinical outcomes at midterm follow-up when compared with conventional meniscal repair. The authors concluded that additional studies are needed to determine the efficacy of meniscal repair augmented with PRP. Therefore, the requested PRP injections for the right knee are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested PRP injections for the right knee are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are 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 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.