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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for durable medical equipment (DME) electrical treatment (Nalu neurostimulation system peripheral nerve stimulation. Findings:  The physician reviewer found that 4 randomized control trials, Deer and colleagues reported moderate to strong evidence supporting the use of peripheral nerve stimulation (PNS) to treat pain, including in the sural, superficial peroneal, and lateral femoral cutaneous nerves. In a review of the bioelectrical implications of simulation of the PNS for chronic pain conditions, Deer and colleagues noted that PNS utilization produced consistently high success rates in achieving pain relief in well selected patients when delivered by skilled clinicians. In this case, the records noted a diagnosis of left sural neuropathy. The patient had tried and failed exhaustive conservative therapies, including physical therapy, steroids, and viscosupplementation. She was being managed on Cymbalta and peripheral nerve blocks. Visit notes reported that the patient underwent a left sural nerve PNS Nalu trial without complications. In this clinical setting, current medical literature supports the use of PNS as superior to conservative therapy which has already been tried and failed. Therefore, DME electrical treatment (Nalu neurostimulation system peripheral nerve stimulation)  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 DME electrical treatment (Nalu neurostimulation system peripheral nerve stimulation) 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 service 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 and 3 are board certified in anesthesiology with sub-specialty certification in pain medicine and are actively practicing. Physician reviewer 2 is board certified in physical medicine and rehabilitation with sub-specialty certification in pain medicine 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bariatric surgery with Orbera intragastric balloon (CPT 43999). The records provided for review document that this patient has Class III obesity with a body mass index (BMI) of 47.2 kg/m2. The provider has recommended the Orbera intragastric balloon, which is U.S. Food and Drug Administration (FDA) approved for the treatment of obesity in patients with a BMI of 30-40 kg/m2 (Courcoulas, et al.; Vyas, et al.). The Orbera intragastric balloon lacks data supporting its use in patients with a BMI over 40 kg/m2. In addition, the guidelines from the American College of Cardiology (ACC), American Heart Association (AHA), and the Obesity Society do not recommend intragastric balloon therapy for long-term obesity therapy (Jensen, et al.). Alternatives, such as bariatric surgery, are recommended in patients with a BMI of 40 kg/m2 or higher, and multiple options such as pharmacotherapy are also supported (Jensen, et al; Kim, et al). For these reasons, the requested bariatric surgery with Orbera intragastric balloon (CPT 43999) is 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 bariatric surgery with Orbera intragastric balloon (CPT 43999) is 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 services are 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 internal medicine with subspecialty certification in gastroenterology and is actively practicing. Physician reviewer 2 is board certified in surgery and is actively practicing. Physician reviewer 3 is board certified in surgery with subspecialty certification in bariatric and minimally invasive surgery 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Harvoni. The American Association for the Study of Liver Diseases (AASLD) and the Infectious  Diseases Society of America (IDSA) recommendations for the treatment of hepatitis C state, From a medical standpoint, data continue to accumulate that demonstrate the many benefits, both intrahepatic and extrahepatic, that accompany hepatitis C virus (HCV) eradication. Therefore, the panel continues to recommend treatment for all patients with chronic HCV infection, except those with a short life expectancy that cannot be remediated by HCV treatment, liver transplantation, or another directed therapy. Given that this patient has a documented infection of hepatitis C, with a recent viral load of 993,000 IU/mL, the requested medication is medically indicated. Therefore, Harvoni is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in infectious 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: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for emergency medical services. Applying Sections 1317.1(a) and 1317.1(b), a portion of the laboratory testing including lipase, comprehensive metabolic panel, and lipid panel, and the physical examination were provided for the treatment of an emergency medical condition. The patient initially reported symptoms concerning for acute pancreatitis, and elevated triglycerides were found, which can cause acute pancreatitis. A diagnosis of acute pancreatitis requires two of three findings, including symptoms consistent with pancreatitis, elevated lipase greater than three times the upper limit of normal, and/or imaging consistent with pancreatitis (Banks, et al.; Garber, et al.). In order to determine whether acute pancreatitis was present, the patients lipase had to be tested. Additionally, the chemistry panel was appropriate to assess for causes of further causes of pancreatitis, such as biliary obstruction and acute kidney injury (Nassar and Qunibi). These services were appropriate for evaluation of the patients medical condition, which manifested itself by acute symptoms of sufficient severity such that the absence of immediate medical attention would reasonably have been expected to result in placing the patients health in serious jeopardy or cause serious impairment to bodily functions. However, the remainder of the services provided were not provided for the treatment of an emergent medical condition. Moreover, emergent assessment of hemoglobin A1C, microalbumin, thyroid stimulating hormone, and free T4 are not supported for any indication documented in the provided records (Marathe, et al.; Jonklaas, et al.). The services provided on additional dates of service were not required in an emergent fashion as the patients condition was no longer concerning for an acute disease process. Similarly, the services additional dates of service were not urgent care services defined by services to prevent serious deterioration of the patients health resulting from unforeseen illness or injury for which treatment cannot be delayed until the patient returned to the Health Plans service area. For these reasons, the physical examination and laboratory testing including lipase, comprehensive metabolic panel, and lipid panel were emergency medical services, while the remainder of the services were not emergency medical services. Final Result: The reviewer determined that a portion of the services at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with 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 transcranial magnetic stimulation (TMS) services. Findings:  The physician reviewer found that At issue in this case is whether the TMS services to treat the patients mental health or substance use disorder are medically necessary as defined in Health and Safety code section 1374(a)(3)(A) set forth below. Medically necessary treatment of a mental health or substance use disorder means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of that illness, injury, condition, or its symptoms, in a manner that is all of the following: (i) in accordance with the generally accepted standards of mental health and substance use disorder care; (ii) clinically appropriate in terms of type, frequency, extent, site, and duration; (iii) not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider.TMS is indicated for severe, recurrent MDD that has not responded to traditional medication and psychotherapy treatment. In this case, TMS had worked to improve patient functioning, allowing her to return to work, and with decreased suicidal ideation. The records show that the patients psychiatrist described partial remission with the 36 sessions. The last five sessions were done bilaterally to adjust for the patients residual symptoms with some improvement. Since TMS was terminated, the patient has reported worsened depressive symptoms and suicidal ideation. Although full remission was not achieved, the patient did have improvement from treatment and would benefit from additional sessions. Further, the patient has reported worsening of symptoms since termination of TMS over a month ago. For these reasons, TMS services are medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Supartz injections in the right knee and prospective authorization and coverage for a Supartz injection series in the right knee.Findings: An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. 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 options are clearly limited. The patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. Therefore, the Supartz injections received in the right knee were medically necessary for treatment of the patients osteoarthritis of the right knee. Additionally, the requested future Supartz injection series in the right knee is medically necessary for the treatment of the patients medical condition. Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for FreeStyle Libre 14-day continuous glucose monitoring system (CGMS) (consisting of a handheld reader and a sensor worn on the back of the upper arm). The FreeStyle Libre is a relatively new CGMS designed specifically to assist patients in monitoring their blood glucose levels at home (Fokkert). Studies have shown that FreeStyle Libre use can help patients improve glycemic control, reduce frequency of hypoglycemic events, and increase overall patient satisfaction (Biodonde, et al.). This patient presents with type 2 diabetes. He has experienced hyperglycemia and he reports that he has been unable to monitor his diabetes with finger sticks. The provider noted that the use of the FreeStyle Libre 14-day will continue to help the patient manage his diabetes. For these reasons, the requested FreeStyle Libre 14-day CGMS (consisting of a handheld reader and a sensor worn on the back of the upper arm) is medically necessary for treatment of this patient. 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 internal medicine with subspecialty certification in diabetes, endocrinology, and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for H.P. Acthar Gel (80 Units twice weekly). This patient presents with minimal change disease per April 2020 renal biopsy. Her provider has recommended retreatment with Acthar Gel give her prior positive response and failure of CellCept, prednisone and rituximab. Madan and colleagues evaluated 37 patients treated with Acthar Gel and found that proteinuria reduction of 30% or greater was shown in 81.1% of patients, and 62.2% showed 50% or greater proteinuria reduction. In addition, the authors observed that the proteinuria responses were greatest in minimal change disease. The authors concluded that, Acthar gel may meet an important treatment need in patients with treatment-resistant nephrotic syndrome in response to first-line therapies, patients unable to tolerate first-line therapies, and in patients with advanced disease. As this patient has undergone treatment with first-line treatment including prednisone, as well as CellCept and rituximab, she is a candidate for treatment with Acthar Gel, which is indicated for patients who are refractory or do not tolerate first-line therapy options. For these reasons, the requested H.P. Acthar Gel (80 Units twice weekly) is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in nephrology 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 an implantable cardioverter defibrillator.The patient is a 48-year-old female who presented to her provider for an electrophysiological study on September of 2015. The electrophysiological study report noted paroxysmal supraventricular tachycardia, likely mediated by atrioventricular nodal reentrant tachycardia, and the patient underwent radiofrequency ablation. Subsequently, she developed a Mobitz second-degree heart block and underwent a permanent dual chamber pacemaker implantation in December of 2015. Because of high thresholds of the right ventricular lead, the pacing system was replaced in December 2017. More recently, the patient developed near-syncope and was found to have nonsustained ventricular tachycardia.  An echocardiogram performed on December 2020 showed normal left ventricular function with no significant valvular disease. Records indicate that the patients medications include atorvastatin, Glucophage, losartan and clonidine. An electrophysiological study with programmed stimulation was performed on early of 2021. This demonstrated inducible nonsustained ventricular tachycardia, and an implantable cardioverter defibrillator was recommended. The patient has requested authorization and coverage for an implantable cardioverter defibrillator. The Health Plan has denied this request and reported that the requested device is not medically necessary for the treatment of the patient.Final Result: The reviewer determined that the requested device 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Vumerity. The U.S. Food and Drug Administration (FDA) approved Vumerity for the treatment of relapsing forms of multiple sclerosis, including clinically isolated syndrome and active secondary progressive multiple sclerosis. The approval of Vumerity was based mainly upon bioequivalence, safety, and efficacy data for Tecfidera since both are metabolized to monomethyl fumarate. This patient indicates that she has failed treatment with Tecfidera, so she requires treatment with Vumerity. However, there is a lack of data demonstrating that Vumerity is more effective than Tecfidera for the treatment of relapsing-remitting multiple sclerosis. Furthermore, the adverse effect profile of Vumerity is similar to Tecfidera. For these reasons, the requested Vumerity 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 neurology 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Stelara. The U.S. Food and Drug Administration (FDA) approves the use of Stelara for the treatment of moderate to severe plaque psoriasis in adults and pediatric patients. Menter and colleagues note that guidelines on the management and treatment of psoriasis do not include step therapy. In this case, given that the provider recommends treatment with Stelara based on the patients clinical history, the requested medication is medically indicated. Therefore, Stelara 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.