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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for onabotulinum toxin A injections. The Health Plan has denied this request indicating that the requested treatment is not medically necessary for treatment of the enrollees migraines. At issue in this case is whether the requested onabotulinum toxin A injections are medically necessary for treatment of the enrollees medical condition. A study concluded that in chronic migraines, botulinum toxin type A might reduce the number of migraine days per month by two days. The guidelines define chronic migraine as 15 days or more per month with a headache lasting four hours or more. The patient meets this definition. The patient has failed other conservative treatments. He is taking sertraline and gabapentin and frequency has improved greater than seven days from use of onabotulinum toxin A injections every 3 months for the past year. Therefore, the requested medication is medically necessary.Final Result: The reviewer determined that the requested treatment 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 anesthesiology with subspecialty certification 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Keytruda (pembrolizumab) immunotherapy. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees lung cancer. A study found that adding pembrolizumab to chemotherapy (regardless of programmed death-1 (PDL-1) expression) yielded clinical benefit in patients with lung cancer. This patient has an adenocarcinoma. National Comprehensive Cancer Network (NCCN) guidelines recommend the use of pembrolizumab with chemotherapy in adenocarcinoma, if the PDL-1 was at least one percent expression. This patient, with zero percent expression, does not fit into either category for which adding pembrolizumab is proven to be of clinical benefit. Therefore, the requested Keytruda (pembrolizumab) immunotherapy is not medically necessary.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in 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

Findings:  The physician reviewer found that the parent of an enrollee has requested authorization and coverage for Xolair 150mg Vial; QT 2, days 28, total fills 12. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees chronic idiopathic urticaria. A review of the record indicates that the enrollee has been diagnosed with chronic idiopathic urticaria and allergic rhinitis. The enrollee has a history of chronic almost daily urticaria since 2014 and that failed to respond with significant improvement from first and second-generation antihistamines. The provider reported the enrollee is doing much better on Xolair, only having a few mild episodes, taking cetirizine as needed only and is no longer needing daily antihistamines. The provider also reported the enrollee is underweight due to food restrictions, but is able to eat some histamine foods and is gaining weight since starting Xolair. The provider is recommending continuing Xolair and following up in six months.The American Academy of Allergy, Asthma, and Immunology (AAAAI) Practice Parameters for treatment of chronic urticaria states that Xolair is indicated for the treatment of refractory chronic urticaria that is unresponsive to conventional therapy. In the case of this patient, medical chart documentation indicates that the patient did not respond to conventional therapy with first or second generation antihistamines (Benadryl and Zyrtec), and H2 antihistamines (Ranitidine), and leukotriene antagonist, (Singulair), per clinic notes. The provider is seeking to lower the overall load of antihistamine for the patient and this is supported by documentation stating that there are suboptimal responses (and chronic almost daily hives) on conventional antihistamines and provided those dates on therapy. Additionally, the provider documented that the enrollees hives are significantly improved, and effectively controlled with Xolair therapy since starting, supporting the continued use of Xolair. 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 allergy and immunology, and pediatrics 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 bilateral knee Euflexxa injections. The Health Plan has denied this request indicating that the requested treatment is not medically necessary for treatment of the enrollees bilateral knee osteoarthritis. At issue in this case is whether the requested bilateral knee Euflexxa injections are medically necessary for treatment of the patients medical condition.A study concluded that hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis in their meta-analysis of 137 studies with 33,243 participants. Hyaluronic acid was found to be better than injected placebo or injected corticosteroids. Nationally recognized evidence based medical guidelines state that hyaluronic acid injections in the knee are recommended; as a possible option for patients with osteoarthritis who have not responded adequately to recommended conservative treatments for at least 3 months; including failure to respond adequately to aspiration and injection of intra-articular steroids. Guidelines support hyaluronic acid injections to potentially delay total knee replacement for patients with pain that interferes with functional activities. The American Medical Society for Sports Medicine (AMSSM) recommends hyaluronan acid for appropriate knee osteoarthritis patients, based on a very large network meta-analysis. Evidence based medical peer-reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Viscosupplementation has been found to be safe and effective and allow for delay of total knee replacement and more effective than corticosteroid injections. In this case, the patient has persistent bilateral knee pain. Significant functional limitations are noted in walking and exercise. Clinical examination findings are consistent with x-ray evidence of bilateral knee tricompartmental osteoarthritis, bone-on-bone in the medial compartment. The enrollee is required to lose weight prior to undergoing total knee replacement and is considering bariatric surgery. The enrollee has failed to respond adequately to other conservative treatment including physical therapy; home exercise program; non-steroidal anti-inflammatory drugs (NSAIDs); and corticosteroid injections. Therefore, the requested Euflexxa injections for the bilateral knees are medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested injections are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for weekly Dialectical Behavior Therapy services. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees medical condition. This patient is being treated for adjustment disorder with anxiety and depressed mood. Based on review of the records provided, it is noted that this patient had mild symptoms reported on her patient questionnaire. The letter by the therapist did not state what the sessions were intended to accomplish other than making conclusions that this patients depression could decompensate into full-blown depression or agoraphobia. The treatment of adjustment disorder with anxiety and depression can be treated with different types of therapy with Dialectic Behavioral Therapy (DBT) being one method of treatment for this disorder as shown by the references noted. Based on review of the records provided it does not appear that this patient requires the requested treatment specifically, therefore the requested services are not medically necessary.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 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: An enrollee has requested authorization and coverage for mastopexy reconstructive surgery. The Health Plan has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees sciatica, neuropathy, tendonitis, and arthritis. The patient who had requested a mastopexy. She had previously undergone panniculectomy. There is insufficient documentation to show that the patient has a functional deficit that has failed reasonable conservative measures. In addition, photographs were not provided to consider the procedure based on a breast reconstruction basis. From the ASPS, the body contouring procedure requested is generally considered cosmetic intervention except in rare circumstances for the arms, thighs and breasts. To satisfy medical necessity, there should be documentation of chronic rashes unresponsive to typical dermatologic treatment or other functional issues should be documented unresponsive to conservative management. Thus, mastopexy for this patient should not be considered medically necessary.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 plastic 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 Euflexxa injections. The Health Plan has denied this request indicating that the requested treatment is not medically necessary for treatment of the enrollees osteoarthritis. A review of the records indicates that the enrollee has been diagnosed with bilateral knee osteoarthritis with associated catching, locking, and effusion. The physical examination revealed mild knee effusion, lateral joint line tenderness, and range of motion 0-130 degrees bilaterally. Radiographic imaging was documented to reveal significant findings. The diagnoses included bilateral primary osteoarthritis of the knees. Prior conservative treatment had been tried for more than 6 months, including corticosteroid injections, non-steroidal anti-inflammatory drugs (NSAIDs), and Tylenol with no relief. The treatment plan documented a discussion of conservative treatment and recommended bilateral Euflexxa injections. Evidence based medical peer-reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Viscosupplementation has been found to be safe and effective and allow for delay of total knee replacement, and more effective than corticosteroid injections. In this case, the patient has been diagnosed with bilateral knee osteoarthritis. The patients subjective complaints included persistent bilateral knee pain with intermittent catching. The clinical examination findings are documented and consistent with radiographic and imaging evidence of tricompartmental bilateral knee osteoarthritis. The patient has reportedly failed to respond to other conservative treatment, including NSAIDs, analgesics and corticosteroid injections. Therefore, the requested Euflexxa injections for both knees would be considered 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 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

Findings:  The physician reviewer found that the parent of an enrollee has requested authorization and coverage for the medication Nutropin AQ Nuspin. The Health Plan has denied this medication indicating that the requested medication is not medically necessary for treatment of the enrollees growth hormone deficiency. At issue in this case is whether the requested medication Nutropin AQ Nuspin is medically necessary for treatment of the enrollees medical condition.Researchers suggest that growth hormone treatment be offered to individuals with persistent growth hormone deficiency in the transition period. There is evidence of benefit; however, the specifics of the patient population that benefits, the optimal time to re-initiate treatment and the optimal dose are not clear. Based on the criteria by policy, the request is approved if patient is compliant with the medication, has a growth velocity of more than 3 cm per year, and there are no side effects. The patient meets these criteria. This is a request for continuation of treatment with growth hormone after one year of treatment. Therefore, this patient meets the criteria for continuation of treatment with growth hormone and the medication Nutropin AQ Nuspin is medically necessary.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 pediatrics with a subspecialty certification in pediatric endocrinology 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
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Guardant360 Comprehensive Liquid Biopsy.Findings:  Two of the three physician reviewers found molecular diagnostic studies in non-small cell lung cancer are considered a standard of care. Numerous gene alterations have been identified that impact therapy selection. The National Comprehensive Cancer Network advises broader molecular profiling with the goal of identifying rare driver mutations for which effective drugs may already be available, or to appropriately counsel patients regarding the availability of clinical trials. Broad molecular profiling is a key component of the improvement of care of patients with non-small cell lung cancer. Testing of lung cancer specimens for these alterations is important for identification of potentially efficacious targeted therapies, as well as avoidance of therapies unlikely to provide clinical benefit. Thus, Guardant360 Comprehensive Liquid Biopsy was likely to have been superior over other modalities for evaluating this patient. 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 sub-specialty 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the medication Pylera for the treatment of H. pylori. Findings:  The physician reviewer found that patients who have failed clarithromycin regimens should not be retreated with those due to high risk of resistance and treatment failure. In this case, the patient has failed such a regimen, and another triple therapy regimen. Song and colleague have noted that Pylera has been effective after failure of clarithromycin-containing triple therapy, and in patients who had failure of 3 prior triple therapies including patients resistant to fluoroquinolones and metronidazole. Malfertheiner and colleagues found that the timing of drug administration for Pylera is simpler than use of the generic bismuth quadruple therapy, resulting in a compliance rate above 95%. For these reasons, Pylera has been FDA-approved for the treatment of H. pylori, and the generic alternatives have not. In this case, given the patients prior failure of multiple regimens, and the higher potential for compliance using Pylera, the requested medication is superior to the formulary alternatives. Accordingly, the medication Pylera is medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine, with subspecialty 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Mohs procedures for the right upper arm basal cell lesion and upper back basal cell lesion (CPT codes 17313, 17314, Q4131, and 15271). The Health Plan has denied this request indicating that the requested procedures are not medically necessary for treatment of the enrollees basal cell carcinoma lesions. Per the American Academy of Dermatology, Mohs micrographic surgery is considered appropriate for aggressive, infiltrating basal cell carcinoma (BCC) to prevent recurrence. Mohs micrographic surgery for superficial BCC is considered indeterminate or insufficient evidence to recommend as appropriate. In this case, the patient has infiltrative basal cell carcinoma on the right upper forearm and superficial basal cell carcinoma on the left upper back. Therefore, the Mohs procedures for treatment of the right upper forearm (CPT codes 17313, 17314, Q4131, and 15271) are medically necessary. The Mohs procedures for treatment of the left upper back (CPT codes 17313, 17314, Q4131, and 15271) are not medically necessary.Final Result: The reviewer determined that some of the requested services are 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 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 Guardant360 Comprehensive Liquid Biopsy. Findings:  Two of the three physician reviewers found that molecular diagnostic studies in non-small cell lung cancer are considered a standard of care. Numerous gene alterations have been identified that impact therapy selection. The National Comprehensive Cancer Network advises broader molecular profiling with the goal of identifying rare driver mutations for which effective drugs may already be available, or to appropriately counsel patients regarding the availability of clinical trials. Broad molecular profiling is a key component of the improvement of care of patients with non-small cell lung cancer. Testing of lung cancer specimens for these alterations is important for identification of potentially efficacious targeted therapies, as well as avoidance of therapies unlikely to provide clinical benefit. In sum, Guardant360 Comprehensive Liquid Biopsy was likely to have been more effective than other methods of evaluating this patient. 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 sub-specialty 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.