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 Gamunex-C intravenous immune globulin (IVIG). This patient presents with a history of immunodeficiency due to hypo-immunoglobulinemia. Her disease course has included encephalitis and frequent infections. The provider reported that treatment with IVIG has stabilized the patients condition. While the patient was not being treated with IVIG, she experience an acute worsening of her condition. Common variable immune deficiency (CVID) is a group of heterogeneous primary immunodeficiencies with impaired immunoglobulin production. CVID is characterized by recurrent and/or severe infections, autoimmunity, malignancy, and allergic disorders (Nguyen, et al.). The potential complications of CVID include bacterial meningitis and viral meningoencephalitis, encephalomyelitis, and peripheral neuropathies (Chavoshzadeh, et al.). The medical literature has demonstrated that treatment with IVIG is safe and effective for patients with CVID. One study reported evidence of subjective improvement in quality of life as well as objective improvement in the frequency and severity of infections (Ameratunga, et al.). Given these findings, the requested Gamunex-C IVIG infusions 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 and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for Mekinist tablets once a day. Findings:  The physician reviewer found that AVM is a rare, congenital vascular growth that progresses throughout life, causing complications that include bleeding, functional deficits, deformity, and high-output cardiac failure. Traditional management with embolization or surgical resection, with or without embolization, carries a high recurrence rate. Currently, there are no approved treatments by the U.S. Food and Drug Administration (FDA) for AVMs. Couto and colleagues have found that mitogen-activated protein kinase 1 (MAP2K1) somatic mutations have been implicated in the development of extracranial AVMs. Therefore, the mitogen-activated protein/extracellular signal-regulated kinase (MEK) inhibitor, Mekinist (trametinib), has been used to treat extracranial AVMs in case reports, according to Lekwuttikarn and colleagues. There are case reports of effectively treating extracranial AVMs in patients who have failed sirolimus. In this case, the patient has an identified PTEN mutation that explains his extensive oncologic history. The patient has previously been treated with maximal dose of sirolimus, without clinical response. The patients pediatric oncologist is requesting coverage for treatment with Mekinist in order to prevent recruitment of new blood vessels to diminish the risk of AVM recurrence. Based on the progressive nature of AVMs, the lack of available FDA-approved medical treatments for AVMs, the high recurrence rates with embolization, and the failure of maximal dose sirolimus in this patient, the use of Mekinist (trametinib) is the best available option for this patient. Therefore, Mekinist tablets once a day is medically necessary for the treatment of the patients medical condition.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 vascular 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for combined treatment with Opdivo (nivolumab) and Yervoy (ipilimumab).The combination of Opdivo (nivolumab) and Yervoy (ipilimumab) is not approved by the U.S. Food and Drug Administration for the treatment of metastatic cervical cancer. Moreover, the combination use is not supported by major drug compendia or the medical literature. Although initial data from the study conducted by Naumann and colleagues suggest benefit, the combined treatment use in cervical cancer requires more robust studies before it can be recommended. Thus, the combined treatment with Opdivo and Yervoy is not medically necessary for the treatment of the patients medical condition.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 internal medicine with sub-specialty certification 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 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 Actemra. Tumor necrosis factor (TNF) inhibitors are contraindicated for patients with lupus due to an increased risk of drug-induced lupus. Verden and colleagues note that the use of Janus kinase (JAK) inhibitors may increase the risk for thrombosis. In this case, the patient has diagnoses of systemic lupus and antiphospholipid syndrome, with a high risk for drug-induced lupus and thrombosis. She has tried and failed multiple medications including methotrexate and leflunomide. In this clinical setting, given that Actemra remains a viable option without an increased risk of drug-induced lupus or thrombosis, the requested medication is medically indicated. Therefore, Actemra is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in rheumatology 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: The parents of an enrollee has requested authorization and coverage for Xeljanz.Findings: Three out of three physician reviewers found that Xeljanz is likely to be more beneficial for you than any available standard therapy.Available treatment options for alopecia areata are limited. This is especially true for diffuse/multifocal involvement, where standard therapies, such as topical steroids, intralesional Kenalog, contact immunotherapy and conventional immunosuppressants (systemic steroids, methotrexate and cyclosporine) are often unsatisfactory and associated with side effects. There is substantial clinical evidence to support the use of oral Janus kinase (JAK) inhibitors, such as tofacitinib, for alopecia areata. A study by Jabbari and colleagues demonstrated approximately 50% hair regrowth as measured by Severity of Alopecia Tool (SALT) scoring. Liu and colleagues performed a study involving patients age 18 years or older with alopecia areata with at least 40% scalp hair loss treated with tofacitinib. The authors found that 77% achieved a clinical response, and 58% of patients had an approximately 50% change in SALT score. Additionally, the medical literature reports that there have been minimal adverse effects reported to date. Moreover, these results are better than what has been reported for contact immunotherapy and systemic steroids, with intralesional steroid being impractical for larger areas of involvement. In conclusion, Xeljanz is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested medication is likely to be more beneficial than any available standard method of evaluation for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewers 1, 2, and 3 are board certified in dermatology 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:  An enrollee has requested authorization and coverage for a new power wheelchair with power seating (seat adjuster).Compliance is the key to pressure injury prevention when the physical capacity to perform the appropriate maneuvers is intact. According to medical literature, lack of compliance can result in pressure ulcer development with or without tools such as power tilt-in-space. A person who has been prescribed bilateral lower limb prostheses, moreover, is someone who has been, or should have been screened and established to have the physical capacity in the upper body to manage this highly demanding task (i.e., ambulation with bilateral lower limb prostheses), which requires upper body strength and conditioning to compensate for the lower limb amputations. This level of physical capacity in the upper body should be more than sufficient to manage using a power wheelchair without power seating features such as power tilt-in-space. In this case, the patient has bilateral lower limb amputations that have healed. She has been prescribed bilateral lower limb prostheses, for which she is undergoing physical therapy and making slow progress with respect to ambulation. In the interim, she has been using a power wheelchair for her functional mobility. There are no indications that the patient requires any other requested features that are not available on her current power mobility device. She does not require power seat elevation for any medical purpose, as she is already independent with her transfers without this feature. She does not require power recline, as she is independent with transfers and she can rest or perform hip flexor stretches outside of her wheelchair. Additionally, there are no objective indications that her current wheelchair does not meet her functional needs. She does not have impairments that would preclude independent pressure relief without power tilt-in-space. Therefore, a new power wheelchair with power seating (seat adjuster) is not medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested durable medical equipment 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for increasing the frequency of Synvisc One injection to the right knee from two injections per year to four injections per year (every three months). Findings:  The physician reviewer found that An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. Viscosupplementation has the maximum effect from five weeks to 13 weeks post injection. After this period, the body starts producing its own hyaluronic acid and the effect of injections lessens. Furthermore, viscosupplementation lasts six months in mild to moderate osteoarthritis and only three to four months in cases of severe osteoarthritis. In this case, there is a history of benefit from viscosupplementation, although because of worsening of the osteoarthritis, the injections now last only three months. Furthermore, the patients options are limited. The patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. Thus, increasing the frequency of Synvisc One injection to the right knee from two injections per year to four injections per year (every three months) is medically necessary for the treatment of the patients medical condition.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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Gardasil human papillomavirus (HPV) three-dose schedule vaccine. Findings: The patient presents with a history of abnormal pap smear and she is at continued risk of cervical cancer. The Gardasil HPV vaccine series is U.S. Food and Drug Administration (FDA) approved for patients ages 9 through 45 years of age for prevention of cervical cancer caused by multiple HPV types. Per a study, vaccination against HPV is recommended to prevent new HPV infections and HPV-associated diseases, including some cancers. This patient may not have been exposed to all the different HPV types thus far, therefore vaccination is still considered protective. Given this support, the requested Gardasil HPV three-dose schedule vaccine 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for a laparoscopic anti-reflux procedure utilizing LINX.According to Saino and colleagues, the standard surgical intervention for GERD, Nissens fundoplication, cannot be performed in this case due to altered anatomy after sleeve gastrectomy. Saino and colleagues indicate that LINX is an effective, alternative procedure for GERD. Further, Hawasli and colleagues reports that LINX is safe and effective for the treatment of gastroesophageal reflux disease after sleeve gastrectomy. In this case, the patient has increased esophageal acid exposure and persistent symptoms of GERD. However, the patient has a history of a sleeve gastrectomy procedure, so a fundoplication cannot be performed. LINX has been shown to be a safe and effective alternative procedure in this clinical setting. Thus, a laparoscopic anti-reflux procedure utilizing LINX is medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for laboratory testing (CPT 82523 collagen crosslinks) provided 3/06/21 by Quest Diagnostics. Findings:  The physician reviewer found that The use of markers of bone turnover is standard practice among endocrinologists and other specialists in osteoporosis and is cited as a tool to monitor therapy in the recent Endocrine Society guidelines for the management of osteoporosis. Collagen crosslinks are bone turnover markers that are used as a guide to monitor compliance and efficacy of treatment. They also help to identify non-responders that require additional work-up for other causes of osteoporosis. Lorentzon and colleagues found that the currently available evidence indicates that the principal clinical utility of bone turnover markers is for monitoring therapy. In this case, the patient's endocrinologist used the information from the collagen crosslink test result to determine whether patient was responding to therapy after 6 months of therapy with Fosamax, a bisphosphonate, which is antiresorptive. Therefore, laboratory testing (CPT 82523 collagen crosslinks) provided 3/06/21 by Quest Diagnostics was likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was likely to have been more beneficial than any available standard method of evaluation for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes, and metabolism 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. Findings: Two out of three physician reviewers found that laboratory testing (CPT 82523 collagen crosslinks) provided 3/06/21 by Quest Diagnostics was likely to be more beneficial for you than any available standard therapy .
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for Spravato (esketamine) Nasal Solution.At issue in this case is whether Spravato (esketamine) Nasal Solution is medically necessary to treat the enrollees mental health or substance use disorder as defined in Health and Safety code section 1374.72(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.According to Zheng and colleagues, intranasal esketamine has an ultra-rapid antidepressant effect in patients with major depressive disorder that lasts for at least 28 days. Moreover, Papakostas and colleagues state, Adjunctive intranasal esketamine for patients with major depressive disorder who are treatment-resistant or acutely suicidal appears to be an effective treatment strategy. In this case, the patient meets the criteria for treatment-resistant depression. This patient saw significant improvement in her symptoms while taking Spravato. It was not until there was a delay in her treatment that the patient saw some regression. Therefore, Spravato (esketamine) Nasal Solution is medically necessary for treatment of the patients medical condition. Treatment with Spravato (esketamine) Nasal Solution is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, Spravato (esketamine) Nasal Solution is clinically appropriate in terms of type, frequency, extent, site, and duration. The requested Spravato (esketamine) Nasal Solution is 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.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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.