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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for a referral to a dermatologist.According to the American Academy of Family Practice physicians, a PCP is essential in serving as a patients first contact for health concerns. Additionally, the authors indicate that the PCP aids in navigating the health care system with patients, including specialist and hospital care coordination and follow-up. Medical literature indicates that PCPs are well educated on common skin conditions, including atopic dermatitis, acne vulgaris, cellulitis/abscess, verruca vulgaris, and benign skin lesions. It would be medically reasonable and appropriate for the PCP to evaluate the patients skin concerns and refer to a dermatology specialist if clinically warranted. In this case, the patient has a skin complaint that should be evaluated. The family history of skin cancer, while important, would not affect the decision to have the PCP evaluate the patients concerns. The medical literature does not support a referral to a dermatologist at this time. It would be within the standard of care for a PCP to evaluate the skin concern initially. Therefore, the requested referral to a dermatologist is not medically necessary for treatment of the patients medical condition.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 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: Overturned Decision of Health Plan

Findings:  The physician reviewer found that The patient has requested authorization and coverage for an esophagogastroduodenoscopy (EGD). The American Society for Gastrointestinal Endoscopy (ASGE) guidelines state that endoscopy may be warranted if an appropriate empirical trial of therapy for a suspected benign digestive disorder has been unsuccessful. Kim and colleagues note that gastric cancer screening with endoscopy should be considered in individuals from regions associated with a high risk of gastric cancer, including Asia, or who have a family history of gastric cancer.  In this case, the patient is of Asian origin with a family history of gastric cancer and has been treated with omeprazole with sucralfate. In this clinical setting, the requested service is medically indicated to evaluate the patients gastrointestinal symptoms. Therefore, an EGD is medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Findings:  The physician reviewer found that An enrollee has requested authorization and coverage for body contouring surgery.At issue is whether the requested body contouring surgery to treat the patients mental health or substance use disorder is 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.The current medical evidence supports the requested services in this clinical setting. This patient has been diagnosed with gender dysphoria. Per the submitted documentation, the patient has been receiving hormone therapy. The patient reports significant anxiety, depression and distress due to their gender dysphoria. Coleman and colleagues listed body contouring procedures as treatments for gender dysphoria. The World Professional Association for Transgender Health (WPATH) position statement on the medical necessity of gender affirming treatments states, Non-genital surgical procedures are routinely performed.these surgical interventions are often of greater practical significance in the patients daily life than reconstruction of the genitals. The requested services are in accordance with the generally accepted standards of mental health and substance use disorder care. Body contouring surgery is clinically appropriate in terms of type, frequency, extent, site, and duration. The requested services are 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. Therefore, the requested body contouring surgery is medically necessary for the 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for proton beam therapy.According to Hug, in the vast majority of cases, intensity modulated radiation or three-dimensional conformal techniques with photons is able to achieve an acceptable cardiac and lung dose. Furthermore, treatments using deep inspiratory breath hold which move the heart away from the chest wall are also associated with very low cardiac doses in patients receiving radiation for breast cancer. Although the comparison planning shows lower heart doses with the proton plan, the standard plan with photons is not representative of typical cardiac or lung doses with intensity modulation or breath hold techniques. Hug indicated that more evidence is needed to support the use of proton beam therapy for the treatment of breast cancer. Additionally, the National Comprehensive Cancer Network (NCCN) guidelines do not endorse the routine use of proton beam therapy in the treatment of breast cancer. Furthermore, consensus group guidelines do not support the use of proton beam therapy in this setting. In this case, there is insufficient data to suggest that proton beam therapy would be associated with less side effects. Based on these reasons, proton beam therapy is not medically necessary for treatment of the patients medical condition.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 radiation oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Findings:  The physician reviewer found that An enrollee has requested authorization and coverage for lidocaine 5% patches.A review of the U.S. Food and Drug Administrations (FDA) Drug Information on ZTLIDO (lidocaine topical system) states that the lidocaine patch is only approved for use in treating post-herpetic neuralgia. A review by McColgan and colleagues states that there has been no evidence to support the use of lidocaine patches for musculoskeletal pain. A systematic review completed by Santana and colleagues evaluated the medical evidence supporting the use of lidocaine patches for chronic low back pain. The authors reviewed seven studies and concluded, We found no randomized controlled trials with substantial evidence to support the use of 5% lidocaine patch in chronic low back pain. In this case, the patient has been diagnosed with cervical radiculopathy for musculoskeletal back pain. Currently, the FDA has not approved the patches for this use, and the recent reviews on this subject reinforce the lack of evidence for use of the lidocaine patches in musculoskeletal related chronic pain. Thus, the requested lidocaine 5% patches are not medically necessary for treatment of the patients medical condition.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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for proton beam radiation therapy for 28 fraction treatments with hydrogel placement. This patient presents with a history of Gleason 3+4 prostate cancer in the right lateral mid and in the magnetic resonance imaging (MRI) target, Gleason 3+3 in the right medial and lateral base, the right medial mid and right medial and lateral apex. The patients provider has recommended treatment with proton beam radiation therapy with hydrogel placement. Proton therapy is being studied for its potential role in the treatment of various forms of cancer. As noted in the medical literature, proton therapy has a Bragg peak, resulting in decreased dose before and after the peak. This translates into a decrease in exposure of normal tissue in the low- to intermediate-dose range, but not in the high-dose range. Dosimetric studies have shown a benefit in bladder and rectal exposure. However, this dosimetric benefit has not been demonstrated to translate into actual decreased clinical side effects (Coen, et al.; Hoppe, et al.). The largest retrospective study showed that gastrointestinal toxicity was higher with proton therapy (Sheets, et al.). In addition, the National Comprehensive Cancer Network (NCCN) guidelines state that, The NCCN Panel believes no clear evidence supports a benefit or decrement to proton therapy over IMRT for either treatment efficacy or long-term toxicity. Therefore, the requested proton beam radiation therapy for 28 fraction treatments with hydrogel placement is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested proton beam radiation therapy for 28 fraction treatments with hydrogel placement is not likely to be more beneficial for treatment of the patients 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 radiation oncology and is actively practicing. Physician reviewer 2 is board certified in radiation oncology and is actively practicing. Physician reviewer 3 is board certified in radiation oncology 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for matrix associated autologous chondrocyte implantation (MACI) for a derangement of the left knee.Findings: Two out of three physician reviewers found that matrix associated autologous chondrocyte implantation (MACI) for a derangement of the left knee is likely to be more beneficial for the enrollee than any available standard therapy.MACI is a well-established treatment for full-thickness cartilage defects. Favorable MACI outcomes have been demonstrated in several significant studies. A study by Saris and colleagues found statistically significant improvements in pain, function, and quality of life for patients who underwent MACI compared with microfracture surgery. The improvements that were noted in patients that underwent MACI were sustained at a minimum of two years with the MACI technique. A five-year follow-up study published by Brittberg and colleagues further demonstrated clinical durability when compared with microfracture treatment. MACI was approved by the U.S. Food and Drug Administration (FDA) for symptomatic, single or multiple full-thickness cartilage defects of the knee with or without bone involvement in adults with no size restriction and for any surface of the knee, including patellofemoral joint. A study by Ebert and colleagues concluded, MACI provided high satisfaction levels and tissue durability beyond 10 years. The outcomes of this randomized trial demonstrate a safe 8-week weight-bearing rehabilitation protocol without jeopardizing longer-term outcomes. In this case, the patient has several full-thickness chondral defects following a severe knee injury. The patients condition has been shown by the medical literature to be effectively managed by MACI. Per the records, severe pain and disability not responding to conservative treatment persisted. The patients BMI of 31.8 is not a contraindication for MACI. According to FDA guidelines, the BMI cut-off is 35. Therefore, MACI for a derangement of the left knee is likely to be more beneficial than any other available standard therapy for the patients condition.Final Result: The reviewers determined that the requested service is likely to be more beneficial than any available standard treatment for the patients medical condition. Therefore, the Health Plans denial should be overturn.Credentials/Qualifications: The reviewer 1, reviewer 2, and reviewer 3 are board certified in board certified in orthopedic surgery. All reviewers 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for convergent ablation maze procedure (CPT 33266). The convergent atrial fibrillation ablation procedure is a combined minimally invasive, epicardial, surgical and endocardial catheter ablation. It is a newer procedure, and while there are some data supporting its use, further research and larger patient studies are needed to determine its efficacy and safety. DeLurgio and colleagues report that the hybrid convergent procedure had superior effectiveness compared to catheter ablation for the treatment of persistent and long-standing persistent atrial fibrillation; however, this conclusion was based on a small study of 149 patients. Therefore, a convergent ablation maze procedure (CPT 33266) is not 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 convergent ablation maze procedure (CPT 33266) 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 service is 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 and 3 are board certified in internal medicine with sub-specialty certifications in cardiovascular disease and in clinical cardiac electrophysiology and are actively practicing. Physician reviewer 2 is board certified in internal medicine with sub-specialty certification in cardiovascular disease 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 patient has requested authorization and coverage for Nurtec 75 mg tablets. The records provided for review document that this patient has a history of migraines. The provider reports that the patients symptoms that have not substantially improved despite treatment with nortriptyline, Topamax, Riboflavin, Propranolol, and Maxalt. The patients provider has recommended treatment with rimegepant (Nurtec). The U.S. Food and Drug Administration (FDA) has approved Nurtec for the treatment of patients with migraine. Nurtec is in the calcitonin gene-related peptide receptor (CGRP) antagonist family of medications that has been demonstrated in clinical trials to be safe and effective in the management of patients with migraine. Researchers reported on a double-blind randomized controlled clinical trial comparing Nurtec to placebo. The authors concluded that, In the acute treatment of migraine, a single 75 mg dose of rimegepant [Nurtec] in an orally disintegrating tablet formulation was more effective than placebo. Given these findings, the requested Nurtec 75 mg tablets 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 neurology with subspecialty certification in vascular 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for an invasive coronary angiography and related services (CPT codes 93458 and 92943). Fathala notes that coronary computed tomography angiography (CCTA) is a perioperative screening tool for detecting patients at high cardiac risk. The American College of Cardiology/American Heart Association guidelines on perioperative cardiovascular evaluation and management do not generally support the use of a coronary angiography in the absence of detectable, significant myocardial ischemia. In this case, given that the patients stress test and clinical findings, including good exercise tolerance and the absence of ischemic symptoms, predicted a low perioperative cardiac risk, and as a CCTA reported that a finding of moderate stenosis was likely overestimated due to the calcification in the segment, the requested service is not medically indicated. Therefore, an invasive coronary angiography and related services (CPT codes 93458 and 92943) are not medically necessary for the 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 internal medicine with sub-specialty certification in cardiology 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 Synvisc-One injection in left knee. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as routine treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patient has a history of prior viscosupplementation which was greatly beneficial. Furthermore, cortisone is contraindicated due to rheumatoid arthritis and possible gallbladder issues. Due to the patients mild osteoarthritis, she is not a candidate for a total knee arthroplasty. Given these findings, the requested Synvisc-One injection in left knee is 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 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.