Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

An enrollee has requested authorization and coverage for osteochondral graft plug. Researchers concluded that the use of an osteochondral allograft is a desirable treatment option for end-stage degenerative joint disease of the first metatarsophalangeal joint. Researchers also concluded that autologous osteochondral plug transplantation represents a potentially successful surgical option in preserving the metatarsophalangeal joint in patients in which conservative and surgical treatments have proved to be ineffective. This patient presents with persistent disabling left second toe pain and dysfunction. Her walking tolerance and activities of daily living are significantly limited. She has sustained multiple traumas to the left second toe over the past several months with acute onset of pain, swelling, and bruising. Clinical examination findings are consistent with radiographic evidence of a left second toe displaced Cartiva implant, medial wall fracture, and fracture fragment impeding dorsiflexion. The provider has recommended a salvage procedure to restore near-normal anatomy, allowing for normal second toe function and preservation of other foot structures. The alternative is removal of the metatarsal head, which would cause significant functional limitations. In this case, the osteochondral allograft plug in an attempt to restore normal function and pain management. Therefore, the requested osteochondral graft plug is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested osteochondral graft plug is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested medical device 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 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.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

An enrollee has requested authorization and coverage for certolizumab (Cimzia) 400 mg every two weeks.Findings:  Two of three physician reviewers found that there is sufficient support for the requested medication in this clinical setting. The certolizumab level in the patient is below the threshold necessary for this drug to provide maximal efficacy. Well performed trials looking at the expected disease response based on drug levels demonstrate that a minimal drug level of approximately 30 should be pursued. The patient has significantly active Crohns Disease accounting for her symptoms. She has already failed two other biologics and has had extensive surgery. She has developed no antibodies to certolizumab. She is also pregnant, making certolizumab an ideal medication, as it is safe for her during pregnancy because it does not cross the placenta or get secreted during lactation. Accordingly, the medication certolizumab (Cimzia) 400 mg every two weeks is likely to be more beneficial than any other available standard treatments for the patients medical condition.Final Result: Two of three reviewers determined that the requested medication is likely to be more beneficial than any other available standard treatment for the patients medical condition. 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 gastroenterology, and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has requested authorization and coverage for bilateral custom solid ankle foot orthoses (AFOs). Researchers concluded that an AFO immediately improves the dropped foot in the stance and swing phases. Medical literature states that their results suggest that bilateral custom-made AFOs plus walking shoes is effective in improving balance compared to walking shoes alone. This patient presents with bilateral foot drop and knee hyperextension. He has tried two off-the-shelf AFOs, which provided inadequate hyperextension control of the knee during the midstance phase of gait. He has finished physical therapy with an increase in his stamina and minimized use of a wheelchair. He is using a rolling walker and is ambulating approximately 100 feet. Bilateral custom solid AFOs with hyperextension control, dorsiflexion assist, three-point varus control, and lateral containment have been recommended to achieve maximize function and normalize gait. Current evidence-based medical literature supports the requested bilateral custom solid AFOs in this patients clinical scenario to improve his stance phase and improve balance. All told, the requested bilateral custom solid AFOs are medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested equipment 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for the medication, Aimovig. The enrollee has a ten year history of migraines that sometimes occur every 36 hours. She was seen by her provider for an examination. Her neurological examination was grossly normal. The treatment plan for the migraines included Botox every three months and Imitrex one tablet every four hours, maximum two tablets in 24 hours, every three weeks.  A subcutaneous injection of Aimovig 70 milligrams/milliliter (mg/ml) was given at this visit. Aimovig auto-injector 70 mg/ml, once per month for four months is prescribed.  The record indicates the injection of Aimovig greatly reduced the occurrence of the enrollees migraines. This enrollee has a diagnosis of intractable migraine with aura; without mention of status migrainosus. Prior treatment has been ineffective and the Aimovig injection was noted to have greatly reduced the occurrence of migraines. The medical literature indicates Aimovig is approved for the preventative treatment of migraine headaches. A study showed Erenumab (Aimovig) significantly reduced migraine frequency, reduced the impact of migraines on daily activities, and reduced the use of migraine medication over a period of six months. Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient has requested authorization and coverage for skilled nursing facility (SNF) services. Based on the available documentation, this patient does not require complex wound care or intravenous (IV) medications. The patient does not have a tracheostomy or other daily SNF level skilled nursing need. The patient did not require a SNF admission for his Foley catheter. His pain was controlled. He has not had significant laboratory abnormalities or significant vital sign instability. The patient does not require the specialized skill, knowledge and judgment of a qualified therapist in a SNF. The patient has been limited in his weight bearing status. His physical therapy notes reveal identical functional outcomes that do not support treatment in a SNF. The patient did not require a SNF admission with daily physical therapy or occupational therapy. Skilled nursing and skilled therapy services are not medically necessary on a daily basis. Therefore, the SNF services were not and 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 with subspecialty certification in neuromuscular 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of an enrollee has requested authorization and coverage for Kallmann Syndrome panel genetic testing.Findings:  Three of three physician reviewers found that there is sufficient support for the requested services in this clinical setting. Many underlying conditions can lead to primary amenorrhea in young women. Typically, the diagnosis of Kallmann Syndrome is suspected by the pediatrician and made by a pediatric/adult endocrinologist. As this is a genetic condition, testing for the various different genetic forms of this disease may also assist in making the diagnosis. From the pediatric endocrinologist perspective, an accurate diagnosis needs to be obtained. Clinical presentations similar to Kallmann Syndrome can occur from other causes disease process. In Kallmann Syndrome, the genetic presentation can have a variety of different clinical manifestations and it is important to have an idea of the specific genetic presentation in the management of these patient in order to help select the correct management and mange the disease process. Once pubertal maturation is achieved, if Kallmann Syndrome subjects wish to be fertile, either injections of pituitary hormones (the gonadotropins, LH and FSH) or in some instances, therapy with the synthetic peptide, GnRH, whose deficiency causes these syndromes, are required to induce the sex organs (testes or ovaries) to make sperm (males) or eggs (females). While Kallmann Syndrome is usually life-long, about 10-15% of patients may experience a recovery of their hormonal system, the reasons for which currently remain unclear. In this case, the patients presentation warrants genetic evaluation to help confirm diagnosis and to help guide management in this rare condition. Accordingly, Kallmann Syndrome panel genetic testing is likely to be more beneficial than any other available standard testing for the patients medical condition.Final Result: The reviewers determined that the requested services are likely to be more beneficial than any other available standard treatment for the patients medical condition. Therefore, the Health Plans denial should be overturned.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: Upheld Decision of Health Plan

The enrollee is requesting reimbursement for proton radiation beam therapy.  The enrollee has squamous cell cancer of the left tonsil that has spread to his left neck lymph nodes. He initially presented to his primary care physician with swelling of the left neck. An ultrasound showed two enlarged submandibular lymph nodes suspicious for malignancy. A left neck lymph node biopsy showed keratinizing squamous cell carcinoma. A computed tomography (CT) scan of the neck showed heterogeneous enlarged lymph nodes in the jugulodigastric chain. It was determined his condition was likely occult oropharyngeal primary. The enrollees radiation oncologist notes that proton therapy may be used to reduce the dosage impact to uninvolved salivary glands, oral cavity, and other normal tissues, reducing short and/or long-term toxicity. The enrollee began proton radiation beam therapy. Proton radiation for the patient's condition is the subject of currently ongoing clinical trials. Definitive conclusions cannot be determined regarding the safety/efficacy of this treatment compared to the standard of care, because there are not enough reported high-quality clinical outcomes available. Studies describe proton beam radiation as useful for treating tumors in challenging locations close to non-targeted critical structures. However, aggressive treatment applied close to these critical structures in patients with tumors in the head and neck region may produce debilitating toxic effects. There is interest in evaluating whether this therapy can improve outcomes for patients with head and neck malignancies. An emerging technology committee routinely evaluates new modalities in radiotherapy and assesses the published evidence to determine recommendations for the society as a whole.  The literature indicates the use of proton beam therapy is recommended for a patient who has a diagnosis of advanced, i.e., T4 and/or unresectable head and neck cancers. More robust prospective clinical trials are needed to determine the appropriate clinical setting for proton beam therapy. Additionally, the patient was not noted to have T4 head and neck cancer and/or unresectable disease. Guidelines address the necessity for enrollment in a clinical trial as there is not enough evidence to support the effectiveness of proton radiation beam therapy in this clinical scenario. Final Result: The reviewer determined that the requested service was not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in radiation 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for the medication, Otezla, 30mg tablets for psoriasis. He has been taking Otezla for two years and it has controlled his condition. Records indicate a small, erythematous scaly plaque on the left flank and papules on both elbows and knees. The enrollee has experienced significant improvement in his psoriasis since he began treatment with Otezla. He does not want to expose himself to the risks of infection or malignancy associated with Enbrel and Humira. He is unable to participate in light therapy due to work requirements. He and his provider believe Otezla presents fewer risks of serious side effects than methotrexate, cyclosporine, or Acitretin. Per the medical literature, apremilast (Otezla) was approved for use in treating moderate-to-severe plaque psoriasis. A clinical study demonstrated that 29 percent of enrollees receiving 20mg of apremilast twice a day and 41 percent of enrollees receiving 30mg of apremilast twice a day achieved a 75-percent reduction in symptoms by week 16. Study participants receiving a placebo achieved a 6-percent reduction in symptoms. This enrollee has moderate to severe psoriasis. He has been taking Otezla and is responding well, according to the records. There are no head-to-head studies comparing the multiple medications available at this time to treat psoriasis.  In a patient such as this, they list apremilast as a first line agent along with multiple other agents. Otezla has been effective in treating this enrollees condition. There is a risk in changing medications at this time that medications, such as methotrexate, cyclosporine, acitretin, Cosentyx, Enbrel or Humira may not be as effective and could result in a flare up and worsening of his condition. Very recent data indicates that patients started on apremilast were as likely as patients started on a biologic agent to still be on the same medication after a year. These data suggest that the effectiveness of apremilast can be expected to continue. Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for the requested medication, Stelara 90mg, every four weeks. The enrollee has Crohns disease and has previously failed treatment with Humira and Cimzia, despite dose optimization. The enrollee was started on Stelara and at his last visit he was doing well on the Stelara, with increased energy. He reported occasional episodes of diarrhea. Biopsies from a colonoscopy, to check for endoscopic remission, showed active inflammation in his small intestine. Thus, ustekinumab (Stelara) levels were ordered. His ustekinumab level was 3.5ng/ml. The enrollee has noticed recurrence of symptoms two to three weeks prior to his next dose. His physician recommended an increase in his ustekinumab dose from 90mg every eight weeks to 90mg every four weeks since the enrollee has already failed two anti- tumor necrosis factor (TNF) agents (Humira and Cimzia), and has had noticeable improvements on Stelara therapy.             In the medical literature, a study analyzed data regarding optimization to help enrollees with Crohns recapture Stelara response. The study analyzed 76 enrollees with active Crohns disease who had their dose escalate from 90mg every eight weeks to 90mg every four weeks because of loss of response or inadequate response. More than half of the enrollees recaptured response after optimization. Another study of subcutaneous ustekinumab for the treatment of anti-TNF resistant Crohns disease, indicated dose escalation was required in 47 percent of enrollees and was successful in 61 percent of those enrollees. In summary, the medical literature supports the use of Stelara with dose escalation giving it at an increased frequency. Final Result: The reviewer determined that the requested services are medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for epidural injections, CPT code 62323 and CPT code 64483. The enrollee has low back pain and left leg weakness, as well as left shoulder pain and weakness following a rollover motor vehicle accident. The enrollee has had a history of chronic low back pain for a number of years and indicates he used to get epidural injections. In an office visit with his orthopedic surgeon, the record indicates the enrollees back pain has gotten to the point where he now cannot walk any significant distance without a limp and he has trouble sleeping at night. He also noted weakness of the left lower extremity and has difficulty with some bowel and bladder functions. During the visit, interpretation of a magnetic resonance imaging (MRI) scan noted prominent L4-L5 and L5-S1 disk bulges with thecal sac impingement. The record indicates the enrollee works laying tiles and has had epidural injections in the past that enable him to return to work. The enrollee has had chiropractic therapy and physical therapy for greater than four weeks.  The pain is progressive and he has noted some bowel and bladder problems but not total incontinence. The enrollee has lumbar radicular pain, significant neurologic signs and MRI documented disc disease with neuroforaminal stenosis. He meets the standard criteria in the medical literature for an epidural steroid injection.  He has failed conservative therapy. The enrollee has had prior epidural steroid injections after which he was able to return to work. The key goal is the ability to obtain relief and return to work after injections. Final Result: The reviewer determined that the requested services are medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in anesthesiology and 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 similar medical condition.