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

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for the medication, Dupixent. The enrollee has eczematous dermatitis affecting 20% of his body surface area (BSA).  Currently he is using betamethasone dipropionate 0.05% ointment and over-the-counter Lamisil cream on his feet. At an office visit, the enrollees rash had recently spread to his trunk, legs, and arms.  It itched all day and worsened after narrowband ultraviolet B (nbUVB) rays.  The enrollee was not a candidate for methotrexate. It was recommended the enrollee stop nbUVB, continue clobetasol 0.05% ointment and start Dupixent (dupilumab). The dermatologist indicates the enrollee has tried and failed clobetasol, a super-high potency topical corticosteroid, and other topical corticosteroids and does not believe further use of topical medications as a sole treatment modality are an appropriate choice because of the extensive BSA affected. A calcineurin inhibitor has not been trialed due to the limited efficacy of the medications and the large surface area that would need to be covered by the medications. Topical calcineurin inhibitors are further not a reasonable option given the common side effects of burning, redness and irritation associated with their applications. The enrollees physician provides a supporting argument as to why the enrollees systemic flare is not ideal for topical treatment; however, there is insufficient evidence in the record that other systemic option treatments, such as oral cyclosporine or a short-course of an oral steroid, were ruled out or trialed before considering biologic treatment with Dupixent. There is no documentation the patient has tried any oral, immunosuppressive treatment in the past to control his medical condition. Systemic therapies include cyclosporine, mycophenolic acid precursors, azathioprine, and methotrexate. The usual systemic treatment for atopic dermatitis has been cyclosporine due to its rapid onset of action, with significant improvement in disease severity seen within a few weeks. Current literature supports the use of biologics for long-term management in patients with moderate to severe atopic dermatitis. The record in this case provides insufficient evidence of whether this patient has moderate-to-severe or mild-to-moderate atopic dermatitis. The severity grading of the patients medical condition is not documented.Final Result: The reviewer determined that the requested service is not 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: Upheld Decision of Health Plan

The enrollee is requesting authorization and coverage for custom foot orthotics. The enrollee has foot pain and difficulty walking due to neuropathy, calcaneal spurs, and tendinitis.  The enrollee has bilateral retro calcaneal spurs.  She reported an infected, painful, swollen left 4th digit of two weeks duration, secondary to use of improper shoe gear at an office visit. Oral Keflex was prescribed with instructions to return, as needed.  The enrollee returned with a blister on the same digit of one-week duration.  She was advised against incision and drainage; and was told to soak, wear wider shoes and follow up with podiatry.  Three days later,  she returned with complaints of discoloration to digits two, three and four on the same foot; despite improvement of the prior blister of the 4th digit.  During this visit the enrollee was diagnosed with toe cyanosis and peripheral vascular disease.  At a podiatry visit, diagnoses included cavus foot, jamming of the first metatarsal, bilateral calcaneal spurs, neuroma and osteoarthritis.  The enrollee saw the podiatrist several times and was x-rayed, biomechanically evaluated and casted for custom orthotics described as UCBL type. Literature shows a high degree of variation among the many published studies on foot orthotics; often either inconclusive or negative in nature. The role of over-the-counter orthotics (OTC) in the relief of pain has been extensively researched. The physician reviewer found that studies determined OTC orthotics were effective in relieving patient foot pain. Therefore, it is reasonable to have a patient try OTC orthotics for diffuse pain, as in the case of this enrollee, rather than immediately prescribe custom orthotics. However, the documentation does not mention any trial of OTC orthotics prior to the prescription of the custom orthotics.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for physical therapy once per week. Charcot-Marie Tooth disease causes muscular deficits in affected patients and restricts a patients ability to perform daily activities. However, there is a lack of scientific evidence on rehabilitation treatment for patients with this condition. In this case, the patient has mild gross motor delays that can be addressed with a home exercise program for strengthening, endurance and coordination of skills. He qualifies for early intervention services that provide ongoing monitoring of milestones and motor skills. In addition, data suggests that a moderate resistance home exercise program may provide strength gains in slowly progressive neuromuscular diseases such as Charcot-Marie Tooth disease. All told, the requested physical therapy once per week is 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 pediatric rehabilitation medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Tremfya. Psoriasis is a chronic inflammatory skin disease that typically presents with sharply demarcated, inflammatory, erythematous plaques. Psoriasis has a high negative impact on the quality of life, especially in patients with moderate to severe disease. Traditional systemic therapies for psoriasis including methotrexate and cyclosporine caused side effects. Treatment with Tremfya has been reportedly beneficial. Tremfya enables the reduction and inhibition of different pro-inflammatory cytokines production, which is involved in psoriasis pathogenesis. Tremfya has been U.S. Food and Drug Administration (FDA) approved for the treatment of patients with moderate to severe psoriasis. Tremfya provides an alternative mechanism of action with high efficacy and good safety profiles, sustained total skin clearance, and rapid onset of effect in psoriasis patients who have previously failed an anti-TNF alpha biologic. This patient presents with moderate to severe psoriasis. Moreover, he has failed treatment with an anti-TNF biologic and responded well to treatment with Tremfya. Given these findings, Tremfya 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient is a 14-year-old male who has been diagnosed with short stature. On 7/14/17, his height was 136.4 cm, which was -1.7 cm standard deviations below the mean, as extrapolated by the expert reviewer using standard pediatric growth charts, placing him in the fourth percentile. On 11/20/17, the patients height was noted to be in the third percentile. A growth chart was not provided with the heights of the patient prior to initiation of growth hormone (GH). Treatment with somatropin was initiated sometime between July 2017 and November 2017. On 9/12/18, the patients height had increased from the third percentile to the tenth percentile, with a height of 149 cm. On 3/15/19, the patients height was 153.9 cm. His bone age was reported to be 13 years and six months at the chronological age of 13 years and seven months. The patients parent has requested authorization and coverage for somatropin (Saizen-Saizenprep). The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether somatropin (Saizen-Saizenprep) is medically necessary for the treatment of the patients medical condition. A study found that GH therapy is appropriate for children diagnosed with idiopathic short stature (ISS) with a current height below -2.25 standard deviations of the mean, in whom the epiphyses are not closed, and whose expected adult height based on bone age is below the normal range. This corresponds to an adult height less than 63 inches for males. Growth hormone therapy was not recommended unless there is compelling evidence supporting the concerns of current or future adverse psychosocial consequences related to short stature. In this case, the patients pre-treatment height was at -1.7 standard deviations below the mean, as extrapolated by the expert reviewer using standard pediatric growth charts, which is normal. There was no evidence showing decreased growth velocity for the patients Tanner stage during the year prior to initiation of GH. The medical evidence does not support the requested medication in this clinical setting. Therefore, somatropin (Saizen-Saizenprep) is not medically necessary for the 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 pediatrics with sub-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 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 enrollee is requesting authorization and coverage for SoClean, automated continuous positive airway pressure (CPAP) equipment sanitizer. The enrollee has upper airway resistance syndrome with fragmented nocturnal sleep and excessive daytime sleepiness. She has co-morbidities of hypertension and borderline diabetes.  Pulmonology progress notes indicate an automated continuous positive airway pressure (CPAP) machine was prescribed with a re-evaluation in six to eight weeks.  The records indicate good objective compliance and resolution of symptoms. However, the enrollee reported she had not been able to use her device for several months due to recurrent upper airway infections and dizziness, despite cleaning of the equipment. Studies demonstrate improvements to sleep-related breathing disorders when positive airway pressure (PAP) therapy is utilized. This enrollee used a CPAP unit due to such a disorder. Studies demonstrate CPAP use in obstructive sleep apnea (OSA) patients does not increase upper and lower respiratory tract infections. Despite positive cultures found in CPAP masks in the studies, the patients experienced no higher levels of infection. Although poor equipment cleaning was exhibited in the study population, the association between CPAP use and infection remained negligible. Additionally, CPAP has been in use for 37 years. Cleaning of the equipment with liquid dish soap and hot water has been the standard of care and used for decades. No scientific data demonstrates the use of SoClean, an automated CPAP equipment sanitizer, is better than the usual measures recommended to clean the CPAP machine. Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in sleep 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The enrollees parent is requesting authorization and coverage for laser hair removal for a history of pilonidal disease, status post incision and drainage. The records indicate the enrollee underwent a procedure of incision and drainage (I&D) for an eight centimeter abscess, and an antibiotic course of Ancef. A follow up visit indicated the wound was closed and education was provided including possibility of elective pilonidal cyst excision in the future, good hygiene and hair removal with waxing, Nair or laser hair removal. Follow up at the surgery clinic indicated drainage from the incision site was clear but a 10 day course of antibiotic was prescribed for prophylaxis, and aggressive hygiene and hair removal was advised. At a subsequent follow-up visit, there was no longer any drainage or pain at the incision site and instructions were to return to the clinic as needed. She was doing waxing for hair removal. History at the next visit indicated the enrollee had recently made an appointment for laser hair removal but had also started to notice some increased pain at her coccyx. Five days of prophylactic Bactrim was prescribed. She was given clearance to proceed with laser hair removal. The record does not support the medical necessity of laser hair removal as there are other depilatory methods to remove hair.  The literature is not definitive in its recommendation regarding laser hair depilation for the treatment of pilonidal cyst disease.  Laser hair depilation has shown promise in a small series of patients with pilonidal disease and concluded that laser hair depilation is a promising therapy in the management of pilonidal disease but additional research is needed to determine its effectiveness in preventing recurrence. The medical recommendation for laser depilation for the treatment of pilonidal disease is weak due to poor quality research. There is ongoing research to study the effectiveness of laser hair depilation for the prevention of disease recurrence in adolescents and young adults with pilonidal disease. The physician reviewer found that there is no definitive study to show that laser therapy is medically necessary to treat pilonidal cyst disease. The pilonidal cyst does not constitute an abnormal structure of the enrollees body. The etiology of a pilonidal disease was thought to be congenital due to abnormal skin in the gluteal cleft.  However contemporary theory considers it acquired rather than congenital as the tendency of pilonidal disease to recur following an extensive surgical resection supports the theory that it is acquired. The requested laser hair removal is not being performed to improve function or create a normal appearance to the extent possible.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for Orthovisc injection for the left knee. The enrollee has post-traumatic patellofemoral arthrosis and chondromalacia of the left knee. She had multiple injuries and subsequent procedures to her left knee, including quadriceps tendon repair. She had persistent left knee pain associated with chronic regional pain syndrome (CRPS). After two trials of Orthovisc intra-articular knee injections, the enrollees orthopedist determined her persistent left knee pain was caused by a non-traumatic quadriceps tendon tear due to her multiple graft and cartilage reconstruction surgeries in the past. Thus, the enrollee underwent surgical repair of the left knee with open quadriceps reconstruction with hamstring autograft, and patellar and trochlear cartilage repair. In subsequent post-operative follow-up visits, the orthopedist indicates the enrollees pain significantly improved, allowing her to gradually wean off narcotics and engage in knee muscle strengthening. A subsequent note indicates the enrollee no longer required braces for ambulation. She did however have the expected limitations due to her multiple extension mechanism procedures.  Radiographs showed significant posttraumatic arthrosis due to the increased mobility around the area of the patella in light of her attenuated quadriceps mechanism.  The orthopedist noted this is best managed by a maintenance program with therapy and he prescribed viscosupplementation due to the chondral thinning at her young age. The routine use of Orthovisc to prevent early osteoarthritis of the knee is not supported by much of the medical literature.  However, a review of the literature does show there may be a small statistical improvement. In this case, there are no other options for pain relief and there is no literature to support in favor or against viscosupplementation in a unique case such as this.  In consideration of this enrollees young age, the fact that she has a very complicated left knee problem, with limited other options, and since she has had considerable sustained relief in the past from these injections, Orthovisc injection for the left knee is medically necessary to treat this enrollees medical condition. 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 orthopedic surgery and sports 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 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 positron-emission tomography scan. The enrollee has non-secretory myeloma. The disease progressed and he underwent induction chemotherapy in preparation for an autologous transplant. He received the transplant and one of his chemotherapy agents, Revlimid, was resumed several months later. At a six-week follow-up office visit, he expressed concern regarding a trace amount of blood in his  stool and was advised to see a gastroenterologist if he had any increase in the bleeding and plan for an anoscopy, colonoscopy, or both. A computerized tomography (CT)/positron-emission tomography (PET) scan was ordered to check the status of the myeloma.  The CT scan report indicated no active lesions in the skeletal system while the PET scan showed the enrollees status had slightly improved, with no signs of progression identified. The medical literature indicates bone marrow aspiration biopsy and imaging studies with magnetic resonance imaging (MRI) and/or computed tomography (CT) and/or whole-body fluoro-deoxyglucose (FDG) positron-emission tomography (PET)/CT are recommended as clinically indicated for a patients course of treatment.  PET imaging reliably predicts active myeloma.  It can also assess the extent of active disease, detect extramedullary involvement, or evaluate treatment response.  The literature recommends considering using the same imaging modality used during the initial work-up for the follow-up assessments.  The record indicates the enrollee had previously had a PET scan prior to his autologous transplant. He has not undergone additional imaging since the transplant.  A PET scan is indicated to assess treatment response following the enrollee's autologous transplant, as well as to assess the continued use of Revlimid.  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 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 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 Soma. The American Pain Society (APS) reported a lack of evidence supporting the safety and efficacy of Soma for treatment of low back pain. The APS guidelines reported that the current data has shown benefit with Flexeril as a short-term treatment. Further, the APS cautioned that the potential adverse effects from the long-term use of skeletal muscle relaxants include sedation, addictive potential, and hepatotoxicity. One review concluded that, opioids, the benzodiazepines and carisoprodol alone or in combination are capable of inducing respiratory depression. In this case, the patient has underlying COPD with chronic low back pain and radiculopathy. She has been treated with both Soma and Norco in the past. Considering the patients diagnosis of COPD, the concurrent use of Soma with Norco would increase her risk of respiratory depression. Further, there is a lack of evidence in the medical literature that demonstrates the efficacy of Soma for long-term use in chronic low back pain. The risks in this case outweigh any potential benefit associated with Soma. Therefore, Soma 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 anesthesiology with subspecialty certification in pain management and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.