Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the combination of Otezla (titration pack followed by 30mg twice a day) with Inflectra infusions.Findings: Two out of three physician reviewers found that the requested combination of Otezla (titration pack followed by 30mg twice a day) with Inflectra infusions is not likely to be more beneficial than any other available standard treatment for the patients medical condition.American College of Rheumatology/National Psoriasis Foundation guidelines state that in those patients with active psoriatic arthritis despite TNFi monotherapy, switching to a different TNFi biologic monotherapy is recommended over switching to IL-12/23i biologic, an IL-17i biologic, abatacept, or tofacitinib monotherapy or adding methotrexate to the current TNFi biologic. The largest study for using combination therapy is a retrospective, open label study by Metyas and colleagues involving 22 patients diagnosed with plaque psoriasis and psoriatic arthritis. They concluded that apremilast (Otezla) can be safely combined with all biologic agents in patients with plaque psoriasis or psoriatic arthritis not responding adequately to biologics alone. There are case reports demonstrating efficacy and safety but the current literature fails to demonstrate any large randomized controlled trials. There are no national recommendations for combination therapy for the treatment of psoriatic arthritis with apremilast and another agent. In this case, the patient has active psoriasis and psoriatic arthritis. She has failed 2 TNFi (Humira due to dental infections, and Inflectra due to an incomplete response), IL-17I (Cosentyx due to abdominal pain) and methotrexate (due to abdominal pain). Based upon the submitted documentation, there are other medication classes that the patient has not tried. There is no evidence of subcutaneous methotrexate, another TNFi, abatacept or interleukin (IL) 12/23 (ustekinumab) trials. Therefore, the requested combination of Otezla (titration pack followed by 30mg twice a day) with Inflectra infusions is not likely to be more beneficial than any other available standard treatment for the patients medical condition.Final Result: The reviewers determined that the requested combination of medications is not likely to be more beneficial than any other available standard treatment for the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine, with subspecialty certification in rheumatology, and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and are 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 gastric bypass revision surgery. The records provided for review do not document the presence of an anatomically correctable pathology. There is no assessment provided for review to determine whether the patients gastric bypass remains intact. For patients who present with a relatively intact anatomy, revision of the gastric pouch or outlet has not been demonstrated to result in durable weight loss. In addition, there is a lack of reported ongoing attempts at weight loss, re-engagement with the multidisciplinary program, or use of any medical adjuncts. Moreover, there is a lack of updated dietary, surgical and behavioral evaluations. For these reasons, the requested gastric bypass revision surgery is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in surgery with expertise in bariatric and minimally invasive 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: An enrollee has requested authorization and coverage for the medication Clobetasol Shampoo.Superpotent topical steroids are a first line therapy for mild/localized psoriasis per the joint AAD-NPF guidelines. Furthermore, treatment of the scalp can be difficult given penetration issues with various vehicles/formulations. Clobetasol (Clobex) shampoo is a very reasonable therapy for the treatment of scalp psoriasis given a favorable vehicle/formation to allow for enhanced skin contact in hair bearing areas in comparison to creams, lotions, gels. The guidelines allow for the selection of a vehicle that is most suitable for the patients circumstance. In this case, the patient was diagnosed with seborrheic dermatitis, which has similar treatment considerations as psoriasis. There can also be clinical overlap. Moreover, topical steroids are effective based on multiple studies and are generally considered part of the standard of care management. Therefore, the requested medication, Clobetasol Shampoo, is medically necessary for this patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for this patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in dermatology, with subspecialty certification in dermatopathology, 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 lidocaine patch 5%, quantity 30.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. They 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 chronic low back pain. His records do not show any history of post-herpetic neuralgia or any complaints related to this condition. The records show that the patient has been prescribed lidocaine patches to treat his 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, lidocaine patch 5%, quantity 30 are not medically necessary to treat 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.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: An enrollee has requested reimbursement for wearable cardiac defibrillator (LifeVest).In this case, the patient has hypertrophic cardiomyopathy but no specific risk factors for sudden cardiac death as outlined in published data and American College of Cardiology/American Heart Association guidelines. The patient does not have a history of ventricular tachycardia/ventricular fibrillation, non-sustained ventricular tachycardia on monitor, high risk features on exercise testing, unexplained syncope, severe (>30 mm) left ventricular hypertrophy, large subvalvular gradient, family history of sudden cardiac death, apical aneurysm, or any other high risk features which would indicate the need for permanent implantable cardioverter defibrillator (ICD) placement. His ejection fraction by echocardiogram was normal at 70% and the concomitant Lexiscan finding of LVEF of 38% was most likely a spurious finding based on the normal LVEF of the two-dimensional echocardiogram done at the same admission using Definity contrast enhancement. As he was not currently a candidate for a permanent automated implantable cardioverter defibrillator based on any specific clinical indications, a LifeVest wearable defibrillator would therefore not be indicated as a bridging therapy to a potential permanent ICD. Thus, the wearable cardiac defibrillator (LifeVest) was not medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the service 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 internal medicine with subspecialty certification in cardiovascular disease 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 Spectracell Micronutrient testing. while tiredness is a frequent complaint in primary care, extensive investigations are only warranted in case of specific findings from the history or clinical examination and that attention should instead be focused on depression and psychosocial problems. Clinicians assessing for cognitive impairment should use a brief, validated cognitive assessment instrument in addition to eliciting patient and informant history regarding cognitive concerns. Chronic fatigue syndrome (CFS) is heterogeneous in presentation without diagnostic indicators, therefore, in health care encounters, insight must be gained from the patient's perspective. A clinical approach to the management of bloating and abdominal distension includes a physical examination and basic diagnostic tests, such as complete blood count, celiac serology, abdominal x-ray, and a breath test. In this case, the documentation does not reflect an evaluation for pathological etiologies for the patients symptoms. Given that current medical literature does not support the use of testing for vitamin and nutrient deficiencies in the setting of chronic pain, fatigue, bloating, and cognitive deficits, the requested service is not medically indicated. Therefore, Spectracell Micronutrient testing 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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 gene testing. This patients provider has recommended whole exome sequencing to assist in this patients diagnosis and treatment given his history of autism, intellectual disability, syncope, hallucinations, and arachnoid cyst. Whole exome sequencing is a comprehensive test, which identifies changes in a patients DNA that are causative or related to their medical concerns. In contrast to current sequencing tests that analyze one gene or small groups of related genes, exome sequencing analyzes the exons or coding regions of over 20,000 genes. Neurodevelopmental disorders are often complex clinical scenarios attributed to single-gene mutations that may be detected through exome sequencing. In a recent study, 100 families with 119 patients affected by neurodevelopmental disorders underwent diagnostic whole exome sequencing. The authors found that 40% of the patients tested received a molecular diagnosis, which led to a change in clinical care or impression of the pathophysiology in 49% of newly diagnosed families. In a retrospective cohort study, 78 patients with various neurodevelopmental disabilities and unrevealing work-up were selected to undergo whole exome sequencing. The authors found that the results yielded a presumptive diagnostic rate of 41% and the results affected management for all patients with a presumptive diagnosis. Furthermore, the use of whole exome sequencing has been endorsed by the American College of Medical Genetics and Genomics (ACMGG), which noted that whole exome sequencing should be considered when specific genetic tests available for that phenotype have failed to arrive at a diagnosis. For these reasons, the requested gene testing (CPT 81415 and 81416) is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the requested gene testing is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are likely to be more beneficial for evaluation 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 pediatrics with subspecialty certifications in neurodevelopmental behavioral pediatrics and genetics and is actively practicing. Physician reviewer 2 is board certified in pediatrics with subspecialty certifications in genetics and clinical biochemical genetics and is actively practicing. Physician reviewer 3 is board certified in genetics 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 patients parent has requested authorization and coverage for a Flovent HFA aerosol inhaler. Findings: In this case, the patient has persistent asthma. While an inhaled corticosteroid in the therapeutic regimen is appropriate for the treatment of asthma, the documentation does not reflect that the patient is in distress or has frequent exacerbations of disease. There is no mention of any allergic reactions to alternative formulations, if there is an intention of scaling back higher doses of Flovent, or therapy with intermittent steroids. Therefore, a Flovent HFA aerosol inhaler is not medically necessary to prevent disease, disability, and other health conditions or their progression.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certifications in medical toxicology and pediatric pulmonology 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 bariatric revision surgery (CPT 43848). The weight loss outcomes from revision to gastric bypass after sleeve gastrectomy is heterogenous and variable without consistent weight loss. As noted in the medical literature, conversion to gastric bypass after sleeve gastrectomy is indicated for correction of complications, as general outcomes for weight loss are similar between the two procedures at five-year follow-up. This patient has no complications of her prior sleeve gastrectomy. The patient regained the majority of weight over the past 15 months. The patient endorses daily alcohol consumption, which is concerning for gastric bypass consideration given the unique alcohol pharmacokinetics. Moreover, the records provided for review report normal anatomy without evidence of complications of the sleeve gastrectomy. For these reasons, the requested bariatric revision surgery (CPT 43848) is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in surgery with expertise in bariatric and minimally invasive 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: The patient has requested authorization and coverage for liposuction to remove the fat deposit from the spine. Lipo-accumulation of the dorsocervical fat pad can be a symptom of cortisone hormonal imbalance. Kairys and Schwell noted that, Physical manifestations of excess cortisol levels include moon facies, buffalo hump, easy bruising, abdominal striae, obesity, facial plethora, and hirsutism. The records provided for review document that this patient has a dorsocervical fat pad and she has a history of cervical radiculopathy. As noted in the medical literature, a dorsocervical fat pad is not likely to cause pain. This patients records do not support that the dorsocervical hump is related to pain from her cervical radiculopathy, or that the condition is related to a functional deficit. For these reasons, the requested liposuction to remove the fat deposit from the spine is not medically necessary for 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 the absence of a documented hormonal abnormality, a dorsocervical fat pad is not a result of a congenital defect, a developmental abnormality, trauma, infection, tumor, or disease. This patients condition is not an abnormal structure of the body. There is a lack of documentation that the requested procedure would improve the patients ability to function. In addition, the appearance of the patient is within normal limits. Based on the photographs provided for review, the requested procedure would not provide a more than minimal improvement in the patients appearance. Therefore, the requested liposuction to remove the fat deposit from the spine is not reconstructive in nature for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary and not reconstructive in nature 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Orencia 125 mg/mL. This patient is currently on CellCept with continued inflammatory arthritis symptoms. The patients provider has recommended treatment with Orencia given previous failure of CellCept, hydroxychloroquine, and prednisone. The standard steroid-sparing immunosuppressive agents for the treatment of inflammatory myositis include methotrexate and azathioprine. Although there is a lack of randomized placebo-controlled trials evaluating methotrexate in the treatment inflammatory myositis, retrospective data has demonstrated its long-term safety and efficacy with a significant increase in strength and a decline in prednisone requirements. Currently, there is a paucity of data in the medical literature to support Orencia for the treatment of inflammatory myositis. Tjarnlund and colleagues reported the effects of Orencia on disease activity and muscle biopsy features of 20 patients with dermatomyositis or polymyositis. The authors found evidence that Orencia in the treatment of patients with dermatomyositis and polymyositis can result in lower disease activity. However, the authors reported that adverse events were noted in eight patients ranging from mild to moderate. Additional studies are needed to determine whether Orencia has a clinical role in the treatment of patients with inflammatory arthritis. The patients records do not report previous treatment with methotrexate and azathioprine. For these reasons, the requested Orencia 125 mg/mL is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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.