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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Opsumit. Opsumit is a dual endothelin receptor antagonist indicated for the treatment of World Health Organization (WHO) group I pulmonary artery hypertension (PAH) in patients with class II-III NYHA symptoms. WHO group I patients include those with idiopathic PAH, heritable PAH, PAH caused by connective tissue disorders and PAH caused by congenital heart disease with repaired shunts. Per Pudillo and colleagues, Opsumit has been studied only in patients with WHO group I PAH. Based on the records, the patient does not have documented WHO group I PAH and more likely has WHO group 4 PAH as a result of thromboembolic disease with documented prior pulmonary embolism. Current medical evidence does not support the use of Opsumit in this clinical setting. Therefore, Opsumit is not medically necessary for 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 a subspecialty certificate 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the venous angioplasty. Venous angioplasty, with or without stent placement, can be appropriate for patients who present with venous thoracic outlet syndrome. This patient had findings consistent with chronic venous thoracic outlet syndrome as well as a documented axillosubclavian occlusion with symptoms. The endovascular treatment provided in this case was appropriate based on the current peer-reviewed medical literature. Thus, the venous angioplasty was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the venous angioplasty was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the services at issue were 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:  One reviewer is board certified in surgery with sub-specialty certification in vascular surgery and is actively practicing. One Reviewer is board certified in diagnostic radiology and vascular and interventional radiology and is actively practicing.  One Reviewer is board certified in surgery with sub-specialty certification in vascular surgery and is actively practicing.  All three 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 LINX Reflux Management System. In the peer-reviewed medical literature, Lipham and colleagues found that sphincter augmentation with the LINX Reflux Management System provided long-term clinical benefits as demonstrated by reduced esophageal acid exposure, improved GERD-related quality of life, and cessation of dependence on PPIs, with minimal side effects. The authors concluded that patients with inadequate symptom control with acid suppression therapy may benefit from treatment with sphincter augmentation. This patients records support a diagnosis of GERD based on his mild elevation in DeMeester score while off acid blocker therapy. However, the records also state that he has benefited to a significant degree from Dexilant acid suppression treatment. Therefore, the patients GERD cannot be considered medically refractory. Furthermore, implantation of LINX in this case is not likely to be more beneficial than standard alternatives given his complaints of solid food dysphagia and the absence of symptom correlation with objectively identified acid reflux events. All told, the requested LINX Reflux Management System is not likely to be more beneficial for treatment of this patients GERD than standard treatment modalities. One reviewer found that the requested LINX Reflux Management System is likely to be more beneficial for treatment of this patients GERD than standard treatment modalities.Final Result: Two of the three reviewers determined that the requested service 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:  One reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the gene panel test. This testing is supported by the American College of Obstetricians and Gynecologists as an integral part of the current standard of care. This patients testing included screening for cystic fibrosis and spinal muscular atrophy. Thus, the gene panel test was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings: Three physician reviewers found the gene panel test 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 gene panel test was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in obstetrics and gynecology 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 Rectiv. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees medical condition.The submitted documentation supports the medical necessity of the medication at issue. The use of Rectiv as first-line therapy for anal fissure is supported by guidelines from the American College of Gastroenterology. Rectiv has proven effective in placebo-controlled trials. Treatment of anal fissure with Rectiv is in accordance with generally accepted standards of medical practice and clinically appropriate for this patients condition. The patient has had improvement with this medication. For these reasons, Rectiv is 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 internal medicine with sub-specialty 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: An enrollee has requested reimbursement for skilled nursing facility (SNF) services. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollee, who is status post left hip revision surgery. The submitted documentation supports the medical necessity of the services at issue. Researchers indicated that more therapy hours in SNFs improve outcomes. The patient had not met the occupational therapy and physical therapy goals as set forth at the time of initial evaluation. Occupational therapy noted indicated that the patient had met long-term goals for dressing and toileting and physical therapy notes indicated that goals for ambulation and bed mobility were not met until later.  The patient was receiving skilled physical therapy services and advancing toward rehabilitation goals in preparation for discharge to home.  These skilled therapy services are not consistent with custodial care. Therefore, the SNF services provided were  medically necessary.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 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: A 34-year-old female enrollee has requested authorization and coverage for Cosentyx for treatment of the enrollees psoriasis. Findings:  The physician reviewer found that systemic therapies for psoriasis, including methotrexate and cyclosporine, have a well-documented array of toxicities, particularly end-organ toxicities. Over the past several years, the use of anti-tumor necrosis factor (anti-TNF) biologic therapies for the treatment of moderate to severe psoriasis has been a major clinical and research focus. Despite difficulties with documenting risks, some systemic treatments for psoriasis have been linked with an increased risk of selected cancers. In addition, patients treated with anti-TNF drugs may develop adverse events such as infections, acute infusion and injection reactions, autoimmunity and cardiovascular effects.The U.S. Food and Drug Administration (FDA) has approved secukinumab (Cosentyx) to treat adults with moderate-to-severe plaque psoriasis. Cosentyx was more effective than placebo in studies specifically investigating efficacy in the difficult-to-treat palmoplantar and nail psoriasis populations. Studies investigating drug efficacy in these populations are rare, and treatment options for these patients are limited. Cosentyx  has also shown promising results for the treatment of psoriatic arthritis. The medical records indicate increased disease progression and symptoms despite multiple treatment attempts with topical, methotrexate, and biologic therapies. The records documented a prior trial with the requested medication had beneficial results. Therefore, Cosentyx is 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 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: An enrollee has requested authorization and coverage for biofeedback therapy. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees pelvic floor dysfunction. The submitted documentation supports the requested services in this patients case. Research indicated that biofeedback therapy is effective in the long term management of patients with chronic constipation and dyssynergic defection and is more likely to restore normal bowel function than standard therapy with laxatives. This therapy is well accepted, and has a high rate of success in improving bowel function and helping patients avoid surgery. It is particularly helpful in pelvic dyssynergia. The proposed biofeedback therapy has been shown to be more effective than laxatives. The only other alternative is surgical treatment, which is associated with significant morbidity, and could potentially be avoided with biofeedback therapy. Therefore, the requested biofeedback therapy is 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 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 reimbursement for NuShield. During a LeFort 1 osteotomy, grafting may be required to promote adequate bone-to-bone contact for healing. Options include autogenous bone, allograft or alloplast. One specific advantage of not using an autogenous graft, is to prevent the need for an additional surgical site. Given the description of the defects present in this patients case, the use of an allograft was appropriate and consistent with the current medical literature. Thus, the NuShield provided was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the NuShield provided was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the service at issue was 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:  One reviewer is board certified in oral and maxillofacial surgery and is actively practicing. One Reviewer is board certified in oral and maxillofacial surgery oral and maxillofacial surgery and is actively practicing.  One Reviewer is board certified in oral and maxillofacial surgery and is actively practicing.  All three 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: A male enrollee has requested authorization and coverage for hydrocodone-acetaminophen 10/325mg, one pill every six hours.  The Health Plan has denied this request indicating that the requested medication quantity is not medically necessary for treatment of the enrollees pain. The submitted documentation supports the medical necessity of the requested medication quantity. Norco is an opioid analgesic recommended for pain after a trial of non-opioids have failed. Guidelines offer very specific requirements for the ongoing use of opiate pain medication to treat chronic pain. Recommendations state the lowest possible dose should be used as well as ongoing review and documentation of pain relief, functional status, appropriate medication use and its side effects. It also recommended that providers of opiate medication document the patients response to pain medication, including the duration of symptomatic relief, functional improvements, and the level of pain relief with the medications.  The medical evidence supports the requested medication quantity in this patients case. Therefore, hydrocodone-acetaminophen 10/325mg, one pill every six hours is 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 neurology with sub-specialty in pain 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. Findings:  The physician reviewer found that
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Synvisc injections for both knees.  The American Academy of Orthopaedic Surgeons (AAOS) guidelines do not recommend hyaluronic acid for patients with symptomatic osteoarthritis, based on strong evidence. Numerous hyaluronic acid studies were analyzed, and it was noted that a few individual trials found statistically significant treatment effects, but when combined in a meta-analysis, the evidence did not meet the minimum clinically important improvement thresholds. There is a lack of support for Synvisc injections for both knees in this patients case. Therefore, Synvisc injections for both knees 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 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 been diagnosed with idiopathic pulmonary fibrosis (IPF). The patient had a chest CT scan that found interval extensive progression of pulmonary fibrosis, with increased extensive honeycombing in the bilateral lower lobes, left greater than right, especially in the sub-pleural left lower lobes medially and right lower lobe. The CT scan also revealed an increase in honeycombing in the left upper lobe anteromedially, and to a lesser extent to the anteromedial sub-pleural right upper lobe. The patient was seen for evaluation of idiopathic pulmonary fibrosis. The patient had mild symptoms of coughing with breathlessness. Ultimately, the patient was noted as having dry inspiratory crackles on the physical exam. A chest x-ray was noted to be consistent with reticular opacities. The patient was noted to have had a good exercise test which revealed mild desaturation with significant activity. The patient was noted to have remained extremely active despite their condition. The patient was noted to have a desire to avoid skin hypersensitivity, and was then placed on OFEV in order to avoid potential skin hypersensitivity reactions with Esbriet. The submitted documentation supports the medical necessity of the requested medication. The U.S. Food and Drug Administration (FDA) has approved nintedanib (OFEV) for the treatment of idiopathic pulmonary fibrosis. In addition, the 2015 American Thoracic Society (ATS) Clinical Practice Guideline for the Treatment of Idiopathic Pulmonary Fibrosis provides a conditional recommendation for the use of nintedanib in individuals with idiopathic pulmonary fibrosis. In this case, the patient has been diagnosed with confirmed IPF based upon CT and pulmonary function testing. As the U.S. Food and Drug Administration has approved this medication for treatment of IPF, and current medical literature recommends this medication for IPF, the requested OFEV (nintedanib) is substantiated and supported by literature. Under these circumstances, OFEV 150 mg capsules 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 internal medicine and subspecialty in pulmonary diseases 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.