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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Vascepa. The submitted documentation supports the medical necessity of the requested medication. Rosenson and Eckel note that Vascepa is more than 95 percent icosapent ethyl and that in a small trial of patients with very high fasting triglyceride levels, reduced triglyceride levels up to 45 percent, but did not significantly affect low-density lipoprotein cholesterol (LDL-C) levels. In this clinical setting, given that the patient has hypertriglyceridemia and is unable to take fibrates, the requested medication is medically indicated. Therefore, Vascepa 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a double balloon enteroscopy. American Society for Gastrointestinal Endoscopy (ASGE) guidelines on the role of deep enteroscopy in the management of small bowel disorders note that the double balloon enteroscopy may be appropriate for histologic evaluation of pathology detected by other means, such as wireless capsule endoscopy, or if therapeutic intervention is needed. In this case, the patient had a finding of terminal ileum ulcers on capsule endoscopy, suggestive of Crohn's disease. In this clinical setting, there are lower risk options to evaluate the patients potential small bowel pathology, including a repeat wireless capsule endoscopy to evaluate for resolution, a colonoscopy of the terminal ileum if a biopsy is needed, or computed tomography enterography. Given that a balloon enteroscopy is recommended for evaluation of areas which are not reachable by upper endoscopy or colonoscopy, and has higher procedural risk than alternatives, the requested service is not medically indicated. Therefore, a double balloon enteroscopy is not medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the requested service 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for a continuous passive motion (CPM) machine. There is a lack of evidence in current medical literature supporting the use of a CPM machine following total knee replacement. Chen and colleagues note that while total knee arthroplasty can alleviate pain and improve range of motion, aggressive CPM does not provide additional benefits. Harvey and colleagues explain that CPM is applied by a machine that passively and repeatedly moves the knee through a specified range of motion and may be included in rehabilitation following knee arthroplasty. However, based on data from 24 randomized controlled trials including 1,445 total study subjects, the authors concluded that CPM does not have clinically important effects on active knee flexion range of motion, pain, function or quality of life to justify its routine use. Trzeciak and colleagues note that while there may be a beneficial effect from CPM on subjective assessment of pain level, joint stiffness and functional ability, CPM has no significant advantage in terms of improving clinical measurements. Given the lack of support for the use of CPM following a total knee replacement in influencing clinical outcomes, the equipment at issue was not medically indicated. Therefore, the CPM machine was not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the equipment at issue was 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 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 Octagam (IVIG).Findings: Two out of three physician reviewers found that Octagam (IVIG) is likely to be more beneficial for you than any available standard therapy.AIDP is a known complication following the administration of several vaccines as well as a complication following illness from several pathogens. CIDP is the chronic form of AIDP. AIDP and CIDP have both been documented in the literature after COVID-19 vaccinations as well as COVID-19 illness. Evidence for intravenous immune globulin (IVIG) in the setting of AIDP/CIDP, specifically secondary to COVID infection/vaccination related issues, is limited. AIDP and CIDP are well-known entities with established treatment recommendations. The management of these diseases involves the administration of IVIG. Additionally, IVIG is approved by the U.S. Food and Drug Administration in the setting of CIDP. There is no qualification on the pathogen or vaccine responsible to bring about the pathological immune response. Additionally, considering the novelty of COVID-19, it can be argued a standard therapy does not exist. In this case, neurophysiological testing is consistent with a severe sensory polyneuropathy in the lower extremities. Therefore, Octagam (IVIG) is likely to be more beneficial than any other available standard treatments for the patients medical condition.Final Result: The reviewers determined that the requested medication 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 neurology. 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: The patient has requested The patient has requested reimbursement and prospective authorization and coverage for (1) paravertebral facet joint injection/blocks (CPT 64493) and (2) paravertebral facet joint injection/blocks (CPT 64493). Baroncini  and colleagues report that facet joint injections and medial branch blocks can be employed for chronic low back pain. The authors conclude, Injections for chronic low back pain deriving from facet joints osteoarthritis are encouraging, especially when considering medial branch blocks. Seo and colleagues also note that medial branch nerve blocks and facet joint injections may reduce axial low back pain and improve secondary functional degradation. In this case, the patient has degenerative disc disease, facet arthritis at L5-S1, and a history of chronic low back pain. The records noted management with facet and medial branch block injections of local anesthetic and corticosteroids. Given that current medical literature supports the safety, efficacy, and significant benefit from these injections, the services at issue were and are medically indicated. Therefore, (1) paravertebral facet joint injection/blocks (CPT 64493) and (2) paravertebral facet joint injection/blocks (CPT 64493) were and are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were and 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 Xifaxan (rifaximin 550 mg, one tablet twice daily for 30 days; four refills).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 by Lembo and colleagues, Xifaxan was demonstrated to be effective, with significant symptom improvement for irritable bowel syndrome. The American College of Gastroenterology guidelines for the treatment of irritable bowel syndrome state that rifaximin (Xifaxan) is effective for the treatment of IBS-D. However, clinical trials and the FDA approval for Xifaxan in the treatment of IBS-D support the use of Xifaxan 550 mg three tablets daily for 14 days, but not daily long-term ongoing use. In this case, the patient has IBS-D. The requested dose exceeds the recommendation from the medical literature. Xifaxan is supported for the treatment of the patients IBS-D, but only for a dose of Xifaxan 550 mg, three tablets daily for 14 days. Therefore, Xifaxan (rifaximin) 550 mg, three tablets daily for 14 days are medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested medication is partially 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 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

Findings:  The physician reviewer found that Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for gastric sleeve surgery (CPT 43775).Mechanick and colleagues state, Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity. Clinical decision-making should be evidence-based within the context of a chronic disease. A team approach to perioperative care is mandatory with special attention to nutritional and metabolic issues. Moreover, the medical literature indicates that bariatric surgery for treatment of morbid obesity requires a multidisciplinary evaluation to determine eligibility. In this case, the patient has been diagnosed with morbid obesity. The patient has completed a multidisciplinary evaluation, including a behavioral evaluation and a dietary evaluation. Therefore, the requested gastric sleeve surgery (CPT 43775) 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 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 bilateral lumbar sacral facet joint injections at L3-S1. An updated review regarding facet joint injections from the American Society of Interventional Pain Physicians (ASIPP) noted that there is adequate evidence in selecting patients for facet joint nerve blocks at least three months after onset and failure of conservative management, with strong strength of recommendation for physical examination and clinical assessment (Manchikanti, et al.). Manchikanti and colleagues also stated that, The evidence for lumbar facet joint nerve blocks using local anesthetics with or without steroid for managing chronic low back pain of facet joint origin is fair to good for short- and long-term improvement. On review of the medical literature, the best evidence for the use of medial branch blocks is for diagnostic purposes in anticipation of a radiofrequency ablation procedure (Cohen, et al.). In this case, the patients most recent reported lumbar MRI demonstrated fusion along with signs of foraminal stenosis at the L3-4 and L4-5 areas. The providers notes outline a previously completed cervical medial branch block. However, there is a lack of documentation from the provider regarding the patients back pain complaint, pain intensity scale, referral patterns or previous response to the injections to support an indication for facet joint injections. All told, the requested bilateral lumbar sacral facet joint injections at L3-S1 are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in anesthesiology with subspecialty certification in pain management 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 weekly or biweekly eye movement desensitization and reprocessing (EMDR) therapy services. The records provided for review support diagnoses of depression, anxiety, and post-traumatic stress disorder (PTSD). The provider noted that the patient previously benefited from weekly treatment with EMDR focused psychotherapy. Thus, the provider has recommended additional EMDR services. As noted in the medical literature, treatment with EMDR can be effective for patients with PTSD (Westfall and Nemeroff; Watkins, et al.). Additionally, this patient has benefited from EMDR focused psychotherapy in the past, particularly with improvement in her PTSD symptoms. In this clinical setting, EMDR focused psychotherapy is appropriate to address this patients current symptomatology. EMDR, to be effective, is usually done once or twice weekly. Moreover, the requested EMDR is in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. Given this patients prior response to weekly EMDR treatment, the requested weekly EMDR 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for manual lymphatic drainage massage therapy and hydrotherapy. This patients records support diagnoses of obesity, chronic pain, and hypermobile Ehlers-Danlos syndrome. A diagnosis of lipedema is supported with findings such as a disproportional but symmetric distribution of fatty tissue in the buttocks, thighs and legs, while sparing the abdomen, feet, and hands (Aksoy, et al.). This patients records do not adequately support a diagnosis of lipedema. The records note the presence of pain and easy bruising. Lipedema is often unmasked only after successful weight loss surgery, which selectively reduces non-lipedema adipose tissue while sparing the lipedema (Kruppa, et al.; Sanchez-De la Torre, et al.). Halk and Damstra noted that manual lymphatic drainage has not been demonstrated to be effective on adipose tissue. This patients records do not adequately support lymphedema based on the documented physical examination findings, negative lymphoscintigraphy, and generally unremarkable response of the patients symptomatology to manual lymphatic drainage. Moreover, this patient has already undergone treatment with manual lymphatic drainage without significant benefit in her symptoms. The patient may continue to apply this intervention independently. Thus, the requested manual lymphatic drainage massage therapy is not medically necessary for this patient. Furthermore, there is a lack of indication for hydrotherapy for treatment of this patients medical condition. There is a paucity of high-grade evidence demonstrating the benefit of hydrotherapy for hypermobility syndromes. Exercise in an aquatic setting is one of several modalities that can provide symptom relief for various pain conditions (Baena-Beato, et al.). However, this patients records do not report that the patient requires therapy in a partially weight unloaded environment with the formal guidance, instruction, and supervision of a skilled provider. The records suggest that this patient is able to perform the applicable exercises safely and effectively without provider assistance. Therefore, the requested hydrotherapy is not medically necessary for this patient. Given these findings, the requested manual lymphatic drainage massage therapy and hydrotherapy are not medically necessary for treatment of 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for letermovir (Prevymis).Letermovir (Prevymis) is approved by the U.S. Food and Drug Administration for the prophylaxis of CMV infection and disease in adult CMV-seropositive recipients of an allogeneic hematopoietic stem cell transplant (HSCT). The medical literature also supports the use of letermovir in high risk patients. In this case, the patient is CMV negative and there is no documentation that the patient is high risk for CMV. Therefore, letermovir (Prevymis) is not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in medical oncology 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 an Omnipod (wireless insulin pump) and related supplies. Researchers note that insulin pump use and continuous glucose monitoring are associated with improved glycemic control. While researchers report that improvement of glycemic control among the insulin pumps appears to be fairly consistent, medical literature note that Omnipod users perceived substantial quality of life benefits from the device. In this clinical setting, given that continuous glucose monitoring is associated with improved glycemic control and quality of life, the requested equipment and supplies are medically indicated. Therefore, an Omnipod (wireless insulin pump) and related supplies are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment and supplies 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 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.