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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Otezla. Findings: Systemic non-biologic treatment of psoriasis is indicated when topical treatments do not achieve sufficient control of disease and is especially important for patients with involvement of the scalp or other difficult to treat areas. The U.S. Food and Drug Administration (FDA) has approved several non-biologic systemic options for psoriasis including methotrexate, cyclosporine, acitretin, cyclosporine, and apremilast. However, there are severe potential side effects with these medications and immunosuppressive agents have been associated with increased risk of infection. In addition, the American Academy of Dermatology (AAD) and National Psoriasis Foundation (NPF) guidelines report stronger evidence supporting treatment with Otezla as compared to acitretin. In this case, the records document that the patient has failed topical therapies for treatment of her diagnosis of psoriasis vulgaris including triamcinolone and excimer laser. The records demonstrate that treatment with a systemic non-biologic agent is appropriate for management of this patients condition. Given these findings, the requested Otezla are 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested reimbursement for wilderness therapy services the enrollee received at Pacific Quest. Current medical literature suggests that wilderness therapy may be an effective treatment option for a wide variety of adolescents, including youth with substance abuse problems and adolescents suffering from depression and various other clinical disorders, and may improve interpersonal relationships. However, there is a lack of evidence supporting the claim that outdoor behavioral healthcare programs are superior to standard therapies as a treatment intervention for adolescent substance use and mental health disorders. Few studies directly compare outcomes of outdoor behavioral healthcare programs to other therapeutic interventions. Dobud and Harper note that in a scoping review of direct comparison trials in adventure therapy, only 13 studies met the full inclusion criteria. The authors found few significant differences to isolate specific therapeutic factors. While literature on outdoor behavioral healthcare programs suggest that participants show some level of improvement on behavioral health outcomes, the results are not conclusive. There is a lack of randomized controlled trials or well-designed cohort studies that would allow for causal conclusions about the impact of outdoor behavioral healthcare programs. In this clinical setting, there is a lack of data to support the claim that outdoor behavioral healthcare programs were more effective than other therapies. Therefore, wilderness therapy services the patient received at Pacific Quest were not likely to have been more beneficial for treatment of the patient's condition than any available standard therapy.Findings:  Three of the three physician reviewers found the wilderness therapy services the enrollee received at Pacific Quest were not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were not likely to have been 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 psychiatry with sub-specialty certification in child and adolescent psychiatry 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 patient has requested authorization and coverage for Xolair Findings: A study notes that mast cell activation syndrome (MCAS) is defined by typical clinical symptoms such as urticaria, pigmentosa, unexplained hypotension, flushing, organomegaly, a substantial transient increase in serum tryptase level or an increase in other mast-cell-derived mediators, and a response of clinical symptoms to agents that attenuate the production of mast-cell-derived mediators.  MCAS may present with skin, gastrointestinal, cardiovascular, respiratory and neurologic symptoms. In a study of 55 patients with mast cell disorder associated with debilitating symptoms who received omalizumab treatment, another study documented a complete response in one patient, a major response in 30 patients, and a partial response in 12 patients, resulting in an overall best response rate of 78.2%, or 43 of 55 patients.  The American Academy of Allergy, Asthma, & Immunology (AAAAI) notes that for treatment of MCAS, omalizumab has been reported to reduce mast cell reactivity and sensitivity to activation which can reduce anaphylactic episodes. In this case, the records note that the patient has tried reasonable alternative therapies, such as antihistamines, and the provider has recommended adding cromolyn and a trial of omalizumab. Given that current medical literature supports the use of omalizumab for MCAS, demonstrating sustained clinical response and control of symptoms, the requested medication is medically indicated.  Therefore, Xolair 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 allergy and immunology 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 patient has requested authorization and coverage for proton beam therapy (33 units each of proton treatment delivery simple without compensation (CPT code 77520), proton treatment delivery intermediate (CPT code 77523), and proton treatment delivery complex (CPT code 77525). Kammerer and colleagues report that proton therapy reduces mean heart dose in breast cancer irradiation, probably reducing late cardio-vascular toxicity. Hug notes that in a small but significant percentage of patients requiring adjuvant radiotherapy for left-sided breast cancer, photon-based radiotherapy can lead to cardiac complications during long-term follow-up. The author further notes that proton therapy reduces the integral dose received by normal tissues. In this case, the provided proton/photon plan comparison shows that a photon radiation treatment plan results in excessive heart exposure, leading to an unacceptable and unnecessary risk for cardiac morbidity and mortality, while the proton radiation plan significantly reduces the cardiac exposure to within known safe tolerance limits. In this clinical setting, given that the patient cannot be treated safely and/or effectively with the use of photon-based radiotherapy, the requested services are medically indicated. Therefore, proton beam therapy (33 units each of proton treatment delivery simple without compensation (CPT code 77520), proton treatment delivery intermediate (CPT code 77523), and proton treatment delivery complex (CPT code 77525) are medically necessary for the 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.
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 genetic testing and counseling (CPT 99205, 99215 x 3, 99358, 99354, 96040 x 4, S0562 x 8). This patient presents with bilateral sensorineural hearing loss (SNHL). The patients provider has recommended evaluation with genetic testing to assess the patient for possible congenital causes of SNHL. There is adequate support in the medical literature for use of broad genetic testing such as whole exome sequencing as part of a first-line work-up of pediatric patients with hearing loss. Kim and colleagues reported that, Mild to moderate pediatric SNHL, even if sporadic, features a strong genetic etiology and can manifest via diverse modes of inheritance. Sheppard and colleagues found that exome sequencing has an improved yield compared with clinical testing and may capture diagnoses not initially considered due to subtle clinical phenotypes. On review of the medical literature, the requested evaluation by a medical geneticist, to include complete medical history and examination targeted towards signs and symptoms of an underlying genetic condition, genetic counseling, and genetic testing are recommended for young patients with unexplained SNHL. As this patient has no prior medical history to explain her bilateral SNHL, the requested genetic testing and counseling are appropriate. For these reasons, the requested genetic testing and counseling (CPT 99205, 99215 x 3, 99358, 99354, 96040 x 4, S0562 x 8) are medically necessary for evaluation and treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in pediatrics with subspecialty certifications in clinical genetics and clinical biochemical genetics 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

Findings:  The physician reviewer found that  The patient has requested authorization and coverage for Talicia (amoxicillin-rifabutin-omeprazole capsule DR 250-12.5-10 mg) four capsules every eight hours for 14 days. Chey and colleagues note that first-line treatment of Helicobacter pylori includes bismuth quadruple therapy or concomitant therapy consisting of a proton pump inhibitor, clarithromycin, amoxicillin, and metronidazole. A rifabutin-based salvage regimen may be recommended after other treatment failures. In this case, while the records note that the patient has tried and failed some therapies, given that the submitted documentation does not show trial and failure of bismuth quadruple therapy, the requested medication is not medically indicated. Therefore, Talicia (amoxicillin-rifabutin-omeprazole capsule DR 250-12.5-10 mg) four capsules every eight hours for 14 days 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral periorbital/eyelid corrective surgery. De Jong and Holman state that in a thorough evaluation of blepharoptosis, Margin-reflex distance (MRD) is recorded. This is the distance measured from the corneal light reflex to the upper lid margin (MRD-1) or lower lid margin (MRD-2). MRD-1 less than two to three mm is indicative of blepharoptosis. Lee and colleagues explain that brow ptosis is defined as brows that rest below the supraorbital ridge and that may compromise vision via obstruction of the superior visual fields. In this case, the patient has brows that are at or just below the superior orbital rims bilaterally. Her MRD-1 is 4 mm bilaterally. A photograph showed an upper lid margin over the superior iris and clear of the pupil. The records did not include visual fields. While the patient has descent of her brows, given that her pupils are clear, her MRD-1 is 4 mm bilaterally, and the lack of documentation of blockage of the superior visual field, the requested service is not medically indicated. Accordingly, the requested bilateral periorbital/eyelid corrective surgery is not medically necessary for the treatment of this patient.The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; (2) to create a normal appearance, to the extent possible. In this case, the patients condition is the result of aging and does not constitute an abnormal structure of the body and does not cause a functional impairment. Therefore, bilateral periorbital/eyelid corrective surgery is not reconstructive in nature for this patient. Final Result: The reviewer determined that the requested service 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 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: The patient has requested reimbursement for brain magnetic resonance imaging (MRI) (CPT 70553), and/or head magnetic resonance angiography (MRA) (CPT 70546), and/or neck MRA (CPT 70549). Diplopia is a common symptom identified in ophthalmological and neurological patients with multiple underlying causes. The onset of diplopia is most often sudden, but it can also be gradual, determined by trauma, or spontaneous. While the acute onset is more suggestive of a vascular event but is not specific, the gradual progression or diplopia that has changed the pattern is more indicative of a compressive lesion (Iliescu, et al.). In the diagnosis and management of transient ischemic attack and stroke, imaging of the brain and intracranial and extracranial blood vessels is an important part of the diagnostic assessment. Brain evaluation using MRI is a sensitive way of assessing for brain ischemia (Coutts). In this case, the patient presented with acute and recurrent episodes of diplopia and visual disturbance and has a history of hypertension and hyperlipidemia. As noted in the medical literature, diplopia can be caused by ischemia or stroke. MRI of the brain and MRA of the head and neck have been shown to be important diagnostic modalities in the assessment of patients with when there is concern for transient ischemic attack or stroke. Given this support, the brain MRI (CPT 70553), head MRA (CPT 70546), and neck MRA (CPT 70549) were medically necessary for this patient.Final Result: The reviewer determined that the services at issue were 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 neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested reimbursement and prospective authorization and coverage for food induction program (FIP) from October 2021 and going forward. Medical literatures note that the general approach to diagnosis and treatment of food allergy includes immunoglobulin (Ig) E measurements to specific foods in question for a patient. However, current medical literature does not support an extensive array of blood tests, such as food IgG testing, examining foods to which a patient has not had a reaction or oral desensitization trials for a multitude of foods to which there is no documented history of anaphylaxis. There is a lack of evidence supporting oral dosing protocols for foods that are considered intolerances or IgE mediated allergies based on IgG and patch testing. Therefore, FIP was not and is not likely to be more beneficial for treatment of the patient's condition than any available standard therapyFindings:  Two of the three physician reviewers found the FIP at issue was not and 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 services at issue were not and 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 and in allergy and immunology and is actively practicing. Physician reviewer 2 is board certified in allergy and immunology and is actively practicing. Physician reviewer 3 is board certified in allergy and immunology and in pediatrics 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 an office visit (CPT code 99205) with an infertility specialist. Findings:  The physician reviewer found that The American Society for Reproductive Medicine defines infertility is a disease historically defined by the failure to achieve a successful pregnancy after twelve months or more of appropriate, timed, unprotected intercourse or therapeutic donor insemination. The definition notes that earlier evaluation and treatment may be justified based on medical history and physical findings and is warranted after six months for women over age 35, or after the failure of six cycles of donor insemination due to the associated lower cycle fecundity. In this case, given that the records do not document a failure to conceive with proper sperm exposure and do not document an impairment that will prevent the patient from conceiving upon exposure to sperm, the requested services are not medically indicated. Therefore, an office visit (CPT code 99205) with an infertility specialist is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service 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 obstetrics and gynecology with sub-specialty certification in reproductive endocrinology and infertility 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

Findings:  The physician reviewer found that The patients parent has requested authorization and coverage for wet wipes. In a study of 54 personal hygienic wet wipes, Aschenbeck and Warshaw found a total of 132 ingredients were identified. The authors concluded that there are many potential allergens in personal hygiene wet wipes, especially fragrance and preservatives. In this case, the patient has a history of incontinence, autism, eczema, and peanut allergy. While wet wipes may represent an easy means of cleaning, they may also be exacerbating his eczema and fungal infections. Given that current medical literature identifies wet wipes as a significant source of allergen with resultant contact dermatitis in susceptible individuals, the requested supplies are not medically indicated. Therefore, wet wipes are not medically necessary to treat the patients condition for any of the following: to prevent disease, disability, and other health conditions or their progression; to prolong life; to promote physical and mental health and efficiency; to correct or ameliorate any physical or behavioral conditions.Final Result: The reviewer determined that the requested supplies are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Jublia. Current medical literature demonstrates the moderate effectiveness of topical Jublia against onychomycosis. Findings:  The physician reviewer found that Sugiura and colleagues note that the high nail permeability of efinaconazole (brand name Jublia) and its potent fungicidal activity in the presence of keratin are related to its low keratin affinity, which may contribute to its efficacy in onychomycosis. Lipner and Scher report a complete mycotic cure of 17% in a study of efinaconazole in the treatment of onychomycosis. The authors further advise on the excellent efficacy of efinaconazole, both in vitro and in vivo against typical onychomycotic pathogens. In this case, the patient has bilateral hallux onychomycosis and has tried and failed a 48-week course of topical ciclopirox and a three-month course of oral terbinafine. Given that the provider now recommends continued topical Jublia for the treatment of affected toenails, the requested medication is medically indicated. Therefore, Jublia 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 licensed D.P.M., board certified in podiatry, 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.