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 a Synvisc One injection of the right knee (CPT-J7325). Findings:  The physician reviewer found that Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. 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 tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested service is medically indicated. Therefore, a Synvisc One injection of the right knee (CPT-J7325) is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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 (1) lung biopsy and (2) thyroid biopsy. Haugen and colleagues note that thyroid nodules are a common clinical problem. The authors note that the guiding clinical strategy acknowledges that most thyroid nodules are low risk, and in general only nodules larger than one centimeter should be evaluated. Biopsies are invasive procedures that carry the risk of adverse outcomes for the patient. In this case, the documentation reflects stable and unchanged pulmonary nodules, and small thyroid nodules. The patients condition is being monitored and managed by repeat imaging in one- to two-year intervals. Given that the provider is following standard of care for management of the patients condition, the requested services are not medically indicated. Therefore, a (1) lung biopsy and (2) thyroid biopsy are not medically necessary for the evaluation 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 internal medicine with sub-specialty certifications in pulmonary disease and critical care 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 Enbrel 50 mg/mL auto-injector, dosed at 50 mg two times weekly (#8 for 28-day supply). Enbrel is U.S. Food and Drug Administration (FDA) approved for the treatment of psoriasis and psoriatic arthritis. The Enbrel dosages FDA approved based on the initial studies were 50 mg twice weekly for three months, then 50 mg weekly thereafter. From the American Academy of Dermatology (AAD) treatment guidelines, the recommended maintenance dose of Enbrel after the initial 12 weeks is 50 mg once weekly (Menter, et al.). In addition, Enbrel administered at a dose of 50 mg twice weekly is more efficacious than a dose of 50 mg once weekly and may be required for better disease control in some patients. In this patients clinical setting, the provider reported clinical improvement with Enbrel dosed at 50 mg twice weekly than when dosed at once weekly. Given this support, the requested Enbrel 50 mg/mL auto-injector, dosed at 50 mg two times weekly (#8 for 28-day supply) is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication dosage 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Protopic (tacrolimus) 0.03% ointment. Tacrolimus is a topical calcineurin inhibitor (TCI). A study noted that evidence on the use of TCIs for infants has almost exclusively been collected for pimecrolimus and has consistently confirmed that pimecrolimus is a safe and effective treatment for infants with atopic dermatitis. The authors concluded that after a careful review of the available evidence of clinical trials, post-marketing surveillance, and epidemiological studies, the TCI pimecrolimus offered a safe and effective alternative to topical corticosteroids in infants aged three months and above. In this case, the patient has persistent facial atopic dermatitis and has tried and failed hydrocortisone and triamcinolone. Given that current medical literature supports the safety and efficacy of TCIs for the treatment of atopic dermatitis, and as the provider has recommended a TCI to prevent flares and minimize side effects, the requested medication is medically indicated. Therefore, Protopic (tacrolimus) 0.03% ointment is medically necessary to prevent disease, disability, and other health conditions or their progression.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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Oncotype DX Prostate Cancer Assay (CPT 0047U). Findings:  The physician reviewer found that Current National Comprehensive Cancer Network (NCCN) guidelines support testing with Oncotype DX post-biopsy for patients with low or favorable intermediate risk prostate cancer. This patient presented with Gleason score 3+4 prostate cancer with involvement in one of nine cores biopsied. His provider recommended evaluation with a tumor-based assay, the Oncotype DX Prostate Cancer Assay. Retrospective studies have shown that molecular assays performed on prostate biopsy or radical prostatectomy specimens provide prognostic information independent of NCCN risk groups (Cuzick, et al.; Sinnott, et al.). Patients with clinically localized disease may consider the use of tumor-based molecular assays to assist in treatment decision making consistent with the NCCN recommendations. Tumor-based molecular assays, such as the Oncotype DX Prostate Cancer Assay are considered within the standard of care in this patients clinical setting. Therefore, the Oncotype DX Prostate Cancer Assay (CPT 0047U) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the Oncotype DX Prostate Cancer Assay (CPT 0047U) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in internal medicine with subspecialty certification in medical oncology 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 reimbursement for anesthesia services during a colonoscopy. The American Society for Gastrointestinal Endoscopists (ASGE) guidelines for sedation and anesthesia in gastrointestinal endoscopy do not support the use of monitored anesthesia care in patients without significant health conditions or airway concerns. The guidelines suggest there is high quality evidence to support the use of mild to moderate sedation in healthy uncomplicated endoscopy procedures, as in this patients clinical setting. The standard of care includes minimal or moderate sedation safely delivered by endoscopists for patients who are ASA Classes I, II, or III. The review study performed found that the use of deeper levels of anesthesia was associated with a 13% increase in complications including bowel perforations. In this case, the patient underwent a routine colonoscopy for colonic polyps and evaluation of suspected diverticulitis. The patient was given an ASA classification score of II and there is no evidence in the anesthesia record that the patient had an airway examination or that he presented with a difficult airway. There is no documentation of previous difficulties or problems with anesthesia. There is no reported history of issues with alcohol or substance abuse, or a history of smoking. The patient did not have any significant heart, lung, kidney, or liver disease. Given these findings, the anesthesia services during a colonoscopy were not medically necessary for this patient.  Final Result: The reviewer determined that the services at issue were 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Ilumya. Findings: Psoriasis is a chronic relapsing and remitting disorder of the skin and immune system that can be treated with a multitude of safe and effective treatment modalities including biologic medications. Although the advent of biologic therapies has changed the treatment landscape, disease modifying anti-rheumatic drugs (DMARDs) like methotrexate and acitretin are still widely used, either as monotherapy or in combination with biologic medications. According to the most recent guidelines of care from the American Academy of Dermatology, methotrexate is recommended for the treatment of moderate to severe psoriasis in adults but is less effective than adalimumab and infliximab for cutaneous psoriasis. Cyclosporine is used in psoriasis for its rapid onset of action but usually as a bridge to long-term therapy due to its side effect profile. This patients records do not document adequate trials and failures or contraindications to standard of care therapies to support an indication with Ilumya. Moreover, the Health Plans formulary includes Humira, which is biologic medication that has been shown to be safe and effective for the treatment for this patients medical condition. For these reasons, the requested Ilumya 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for occipital nerve block (CPT 64450). Findings:  The physician reviewer found that records provided for review document that this patient with occipital neuralgia has failed traditional migraine therapies including Tylenol, Advil, Excedrin, and muscle relaxant medications. Her provider has recommended treatment with an occipital nerve block. As noted in the medical literature, greater occipital nerve blocks have been shown to provide well-selected patients an effective treatment modality in the treatment of headaches secondary to greater occipital neuralgia. Greater occipital nerve block intervention can significantly alleviate pain, reduce the number of headache days, and decrease the need for medications in this patients clinical setting. Therefore, the requested occipital nerve block (CPT 64450) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested occipital nerve block (CPT 64450) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in neurology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for home infusions of Panzyga for four days every two months for one year. This patient presents with a history of multiple sclerosis. The patients current medication regimen includes Tecfidera twice daily with continued symptoms. Her provider recommended treatment with Panzyga, which is intravenous immunoglobulin (IVIG) therapy. There has been considerable research on the use of IVIG for the treatment of patients with multiple sclerosis. However, there is a lack of sufficient data to suggest that IVIG treatment provides substantial benefit when compared to currently available therapies. There is a paucity of data from prospective randomized controlled clinical trials reporting on the long-term safety and efficacy of Panzyga for multiple sclerosis. Therefore, the requested home infusions of Panzyga for four days every two months for one year are not 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 home infusions of Panzyga for four days every two months for one year 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 medication is 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 neurology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for intraovarian administration of platelet-rich plasma (platelet-derived growth factor). Intraovarian administration of platelet-rich plasma (PRP) to address poor ovarian reserve resulting from advanced maternal age is not supported in the peer-reviewed medical literature or clinical guidelines. Researchers noted that the current understanding of the activated PRP substrate and its derivative growth factors are in the preliminary stages. The authors concluded that the use of PRP has not been demonstrated to be beneficial for patients of advanced maternal age with poor ovarian reserve. This patient is over 45 years of age and has failed multiple cycles of in vitro fertilization (IVF). There are inadequate data demonstrating that use of intraovarian PRP will improve this patients chances of conceiving or that its use will improve the health of any potentially conceived embryo. Based on current literature, the intraovarian administration of PRP (platelet-derived growth factor) was not 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 intraovarian administration of PRP (platelet-derived growth factor) was 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 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 obstetrics and gynecology and is actively practicing. Physician reviewer 2 is board certified in obstetrics and gynecology with subspecialty certification reproductive endocrinology and is actively practicing. Physician reviewer 3 is board certified in obstetrics and gynecology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for an electric/power scooter he purchased online. In this case, the patient has a history of cerebral palsy. The documentation reflected that the patient had normal strength and range of motion except at the ankles, hands, and fingers. He had diffusely hyper reflexes and spastic gait. Despite his physical impairments, the patient was highly functional overall. The records show a fall, however the circumstances appeared unrelated to the patients cerebral palsy and the records do not reflect a history of regular falls. Following spinal surgery, he was reported to be back to his premorbid baseline. Given that the records do not establish indications that the patient has been unable to accomplish mobility-related activities of daily living, the requested equipment is not medically indicated. Therefore, the electric/power scooter the patient purchased online 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for RTC services. The Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment. With regard to risk of harm, the records support a score of 4. The patient had a serious risk of harm, due to a history of suicide attempts, impulsive high-risk behaviors prior to admission to the RTC, and continued self-harm urges while at the RTC.In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment due to serious deterioration of interpersonal interactions and conflict with her parents and brother, purging, deficits in self-care, and difficulty attending to activities of daily living. With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity, due to the presence of substance abuse. In terms of level of stress of the recovery environment, the records support a score of 2. The patient had a mildly stressful environment due to family conflict. With regard to level of support of the recovery environment, the records support a score of 2 due to her parents participation in treatment and treatment planning. In terms of resiliency and treatment history, the records support a score of 4. The patient had poor resiliency and/or response to treatment due to lack of improvement despite years of treatment at multiple levels of care.With regard to treatment acceptance and engagement, the records support a score of 3. The patient demonstrated incomplete engagement in residential treatment due to her difficulty accepting responsibility and inconsistent participation in treatment.Thus, the patient has a total score of 21. The records support a 4 in terms of risk of harm. In this case, the recommended level of care is medically monitored residence-based services. This is consistent with the level of care that the patient received and is receiving at the RTC. Therefore, RTC services 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 psychiatry with sub-specialty certification in child and adolescent 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.