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

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with left foot pain and hallux limitus. The patient reported left big toe pain. The physical examination revealed a dorsal exostosis with slight pain and crepitus with first metatarsophalangeal (MTP) joint range of motion. The patient has requested authorization and coverage for a custom left foot orthotic. The Health Plan denied the request and reported the requested equipment is not medically necessary for the treatment of this patient. At issue in this case is whether a custom left foot orthotic is medically necessary for the treatment of the patients medical condition. A study by researchers reported that patients utilizing an orthosis, demonstrated increased ability of participants to bear weight on the arthritic hallux MTP joint and restoration of physiologic stance. Compared to existing products, the device was well-tolerated and did not require footwear modifications or impede normal gait. Overall, the orthosis offers an appealing solution to patients dissatisfied with existing treatment options as well as those who may be averse to or ineligible for surgery. Authors reported, Orthotics can be used to modify existing footwear. An extended shank or footplate made of spring-steel or carbon fiber can be used to stiffen the sole of the shoe thereby limiting dorsiflexion at the first MTP joint. A Mortons extension limits movement at the hallux in isolation and may be better tolerated by more active patients. In this case, the patient was noted to have pain and crepitus with first MTP joint range of motion. The patient was also noted to have a dorsal first MTP joint exostosis and hallux limitus. The medical evidence supports the requested equipment in this clinical setting. Therefore, a custom left foot orthotic is medically necessary for the 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 a board-certified podiatrist 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 been diagnosed with hypopituitarism. The patients bone age was noted to be 11 years old with a chronological age of 12 years old. Laboratory results revealed positive thyroid peroxidase antibodies. On 12/9/19, the patients height was noted to be 155.5 cm. The patients height was noted to be 156.5 cm. The patient was being treated with growth hormone (GH). The provider noted that the patients insulin-like growth factor 1 (IGF-1) level was low at 165 ng/mL. The patients height was noted to 158 cm, while being treated with GH. The patients parent has requested authorization and coverage for a Nutropin AQ Nuspin 10 mg/2 mL (5 mg/mL) pen injector. 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 a Nutropin AQ Nuspin 10 mg/2 mL (5 mg/mL) pen injector is medically necessary for the treatment of the patients medical condition. GH deficiency cannot be diagnosed based on one value alone but requires the evidence of poor growth velocity. Researchers reported, We recommend against reliance on GH provocative test results as the sole diagnostic criterion of growth hormone deficiency (GHD).  In this case, there is no evidence the patient has poor growth velocity. Grimberg and colleagues reported, The primary objectives of GH treatment for patients with GHD are acceleration of growth velocity to promote normalization of growth and stature during childhood and attainment of normal adult height (AH) appropriate for the childs genetic potential. The height of each patient is dependent on parental heights. There is no documentation to support that this patient is growing below her genetic potential. In December 2019, the patients bone age was 11 years and her height was 155.5 cm. This gives her an estimated adult height prediction of 169 cm, which is a normal height for an adult woman. The patients pretreatment height is not below -2.25 standard deviations. The medical evidence does not support the requested medication in this clinical setting. Therefore, a Nutropin AQ Nuspin 10 mg/2 mL (5 mg/mL) pen injector 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 in pediatrics with sub-specialty 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for Wide local excision of melanoma in situ.  Per Health and Safety Code section 1345(h), health plans are required to cover urgent care services. Per that same provision, urgent care services are defined as, services to prevent serious deterioration of the enrollees health resulting from unforeseen illness or injury. The records provided for review document that this patient presented to his provider with a diagnosis of melanoma in situ on the cheek, which required excision. Based on the definition of urgent care services, the patients melanoma did not require urgent excision on the date of service. The American Academy of Dermatology (AAD) guidelines on the management of melanoma recommend definitive excision within two months of diagnosis. Moreover, current data suggest that there is a paucity of evidence to suggest that a shorter timeline for removal of the tumor changes long-term patient health outcomes. Based on these findings, the procedure could have been performed within the two-month timeframe without urgent excision on the date of service. A wide local excision by a plastic surgeon or dermatologist was reasonable. There was no reasonable expectation of deterioration in the patients health to support an urgent indication for the procedure. Therefore, the wide local excision of melanoma in situ was not provided for treatment of an urgent medical condition as defined by California law. Final Result: The reviewer determined that the wide local excision of melanoma in situ was not provided for treatment of an urgent medical condition as defined by California law. Therefore, the Health Plans denial should be upheld. 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 has requested reimbursement for a high-efficiency particulate air (HEPA) filter. As noted by Kimura, HEPA filters capture greater than 99% of 0.3 micron diameter particulates in a laboratory setting. This type of filter has multiple industrial applications, including in the hospital setting. A HEPA filter can also be appropriate for patients in the community with profound neutropenia to mitigate the risk of conditions such as aspergillosis. In addition, patients with asthma or allergies whose symptoms persist despite first-line interventions can benefit from placement in a controlled environment where an air purifier with HEPA filter can work to purify the ambient air while minimizing the ongoing intrusion of new airborne particulates. However, the use of HEPA filters outside of controlled clinical settings has not been established. Factors such as open windows, community population density, pets and the presence of flowering plants significantly more impactful with respect to microbial profiles in the household setting than HEPA filters. In this patients case, there is no documented medical indication for the HEPA air purifying system and extra filter provided. The patient is at increased risk for respiratory complications such as aspiration pneumonia, community-acquired pneumonia, atelectasis, and pulmonary embolus due to her underlying conditions, which include cognitive impairment, dysphagia, safety awareness deficits and dysmobility. Based on the available documentation and current medical literature, the use of a HEPA filter is not supported to improve this patients clinical, functional, or other health outcomes. For these reasons, the HEPA filter was not medically necessary for treatment of this patient.Final Result: The reviewer determined that the device at issue was 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 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 authorization and coverage for Gammaplex intravenous immunoglobulin (IVIG) 45 gm x 3 days every four weeks. Although other interventions such as plasma exchange and intravenous methylprednisolone therapy can be beneficial in patients with transverse myelitis, IVIG is supported as safe and effective for use in this patients clinical setting. Duarte and colleagues reported a reduction in intensity and extension of abnormal T2 signal within one week of treatment, symptomatic improvement in the ability to walk, and magnetic resonance imaging (MRI) findings of disease resolution within three months. After excluding other causes, this patient was diagnosed with systemic lupus erythematosus (SLE)-associated longitudinal extensive transverse myelitis. Treatment has included high-dose steroids without substantial improvement. Treatment with IVIG resulted in symptomatic improvement. For these reasons, the requested Gammaplex IVIG 45 gm x 3 days every four weeks is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested Gammaplex IVIG 45 gm x 3 days every four weeks 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 medication 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 reviewer 1 is board certified in neurological surgery and is actively practicing. Physician reviewer 2 is board certified in neurology and is actively practicing. Physician reviewer 3 is board certified in neurology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for 75 mg of Lyrica two times daily and lidocaine topical ointment 5%. In studying the use of pregabalin for neuropathic pain in adults, Researchers concluded there was limited evidence of benefit in neuropathic back pain or sciatica, neuropathic cancer pain, or polyneuropathy. The North American Spine Societys clinical guidelines concluded, There is insufficient evidence to make a recommendation for or against the use of gabapentin in the treatment of lumbar disc herniation with radiculopathy. The U.S. Food and Drug Administration has not approved the use of Lyrica or lidocaine ointment for the treatment of lumbar radiculopathy. There is a lack of studies evaluating the use of lidocaine ointment for lumbar radiculopathy or related neuropathic pain. In this case, the patient has lumbar radiculopathy with neuropathic pain. As she has tried and failed Elavil, gabapentin, and other conservative nonpharmacologic treatments, the patients provider started her on a trial of Lyrica and lidocaine ointment. However, clinical guidelines do not support the use of Lyrica for lumbar radiculopathy, and there are a lack of studies evaluating the use of lidocaine ointment for lower back pain. Therefore, 75 mg of Lyrica two times daily and lidocaine topical ointment 5% are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medications 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 anesthesiology with sub-specialty 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Polar Cube fluid circulating cold pad with pump (HCPCS code E0218) for the right shoulder. In this case, the provider recommended postoperative use of a cold unit to decrease pain, increase healing, and reduce narcotic usage following shoulder surgery. A review of the literature reveals that active cold therapy units, such as the Polar Cube fluid circulating cold pad with pump, have not been demonstrated to provide clinically significant benefits over passive cold compression therapy. Moreover, there is a paucity of high quality trials on the use of active cold therapy units for the treatment of postoperative shoulder pain. One study by Researchers noted that there is a lack of data demonstrating significant benefits with use of compressive cryotherapy over standard ice wraps in patients undergoing shoulder arthroscopy. The submitted documentation does not add extenuating factors that necessitate this device over a standard ice pack after this patients arthroscopic shoulder surgery. Therefore, the Polar Cube fluid circulating cold pad with pump (HCPCS code E0218) for the right shoulder was 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 Polar Cube fluid circulating cold pad with pump (HCPCS code E0218) for the right shoulder was 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 device at issue was 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested coverage for Botox injections in her hands. This patient with a medical history of rheumatoid arthritis, Raynauds syndrome, scleroderma, and carpal and cubital tunnel syndrome of the right hand. She has been treated for these conditions by multiple intravenous and oral medications in the past without successful relief of her symptoms. She reports treatment with three months of daily hyperbaric oxygen chamber, nitroglycerin, nifedipine, sildenafil, and methotrexate, but continued to have painful ulcerations. She has had two fingertip amputations, but since that time has developed recurrent ulcers on her hands. On 6/12/19 and 1/3/20, she was seen by her orthopedic surgeon for significant pain in both hands and given Botox injections. She reports the Botox injections work better than prior treatments and are crucial for her recovery. This patient has scleroderma with digital ulceration that has failed to respond to most treatments. Botox has been shown in the current literature to provide improvement of the symptoms that the patient has related to her medical condition and is appropriate for use in this case. The patient had the injections with proven efficacy, as the injections resulted in decreased pain. Final Result: The reviewer determined that the Botox injections were medically necessary for the treatment of the enrollees medical condition.Credentials/Qualifications: The physician 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 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 Butrans patches (20 mcg per hour dosage). In studying the safety and efficacy of buprenorphine for chronic pain, Pergolizzi and Raffa found that buprenorphine is an equally effective but potentially safer treatment option for chronic pain than full opioid receptor agonists. They concluded that a comparison of current clinical data along with the results of responder and safety analyses supported the use of buprenorphine over full opioid receptor agonists for effective preferential treatment of chronic pain. Webster and colleagues convened an expert panel to reach consensus on the use of buprenorphine for chronic pain management. The panel recommended that buprenorphine be considered before some Schedule II, III, or IV opioids in patients with a favorable risk/benefit profile on the basis of metabolic factors, abuse potential, and tolerability. In this case, the patient has had chronic back pain after lumbar laminectomy and fusion surgeries. His pain was managed with the Butrans patch, Norco, and gabapentin. He was switched to Suboxone, combined with Norco, to manage his chronic pain. The patient found that his current medications were not helpful in managing his pain and requested returning to the Butrans patch. The medical literature validates the efficacy of buprenorphine for use in chronic pain population and as a first-line treatment over traditional full opioid agonists due to better safety profile, tolerability and non-inferior analgesic effects. Therefore, Butrans patches (20 mcg per hour dosage) are 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 anesthesiology with sub-specialty 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: The patient has requested authorization and coverage for an annual pap smear. Researchers concluded that among older women, five-yearly screening is approximately as efficacious as more frequent screening. The U.S. Preventive Services Task Force lists multiple recommendations for cervical cancer screening for patients aged 30 to 65 with normal results. These recommendations include a pap test every three years, HPV testing every five years, or co-testing (pap test and HPV testing) every five years. In this case, the patient does not have a history of abnormal pap smears. For such patients with normal prior history, the medical literature specifies an interval of no sooner than every three years for routine cervical cancer screening. Therefore, an annual pap smear is not medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in obstetrics and gynecology 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:  This is a patient with chronic low back pain. The record reports multiple phone encounters from the patient to providers, for refills of Norco 5/325 180 tablets per month between December 2019 and June 2020. Specialty physicians evaluated the patient in 2020, and their impression was mechanical low back pain without/with extremity pain that may/may not be due to nerve impingement. Conservative care was recommended with non-narcotic medication, physical therapy, topical over the counter medications, heat/cold packs and possibly epidural injections after magnetic resonance imaging (MRI). At issue is whether the requested medication, Norco 5/325mg, 180 tablets per month, is medically necessary to treat the enrollees medical condition. Clinical practice guidelines and literature studies recommend that in patients with chronic low back pain, who have not had a good response to conservative treatment, should first be prescribed non-steroidal anti-inflammatory drugs (NSAID). Opiates should only be considered as an option for acute pain for patients who have failed treatment with conservative treatment and NSAIDs. There is no record of whether conservative treatment has been beneficial for the patient. The lumbar MRI results, recommended to further determine the extent of the patients back issues, have not been reported in the records provided for review.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 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.