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

The enrollee is requesting authorization and coverage for Monovisc injection in the right knee. The enrollee has a history of right meniscus surgery. He described a sudden onset of pain in his right knee after rising from the couch. He was seen by a sports medicine provider for right lateral knee pain. He received a corticosteroid injection and right knee x-ray showed no evidence of fracture or acute bony abnormalities, but it demonstrated tricompartmental osteoarthritis, most severe in the lateral compartment, with near bone-on-bone apposition on the posteroanterior view. The physician also submitted a request for authorization of Monovisc injection for the right knee. Review of the record indicates physical examination showed trace effusion to the right knee with no tenderness.  There was 3-120 degrees range of motion to the right and crepitus with range of motion to the right.  X-rays were obtained showing tricompartmental osteoarthritis most severe in the lateral compartment with near bone-on-bone apposition. According to the medical literature, hyaluronic acid injection is indicated for enrollees with symptomatic osteoarthritis who have not responded adequately to conservative non-pharmacologic therapy and simple analgesics, such as acetaminophen. The medical literature does not recommend the use of hyaluronic acid injections in enrollees with symptomatic osteoarthritis of the knee unless a clear and compelling rationale for an alternative approach is present. The records indicate the enrollee was evaluated for knee pain. The treatment plan included physical therapy and an unloader brace. A corticosteroid injection was administered and a request for Monovisc was submitted. However, there is insufficient evidence of follow-up in the record indicating a clear, compelling rationale for the requested Monovisc injection.  Records do not substantiate the enrollee continues to have symptoms, despite the recommended treatment nor trials of other treatment modalities.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has requested authorization and coverage for panniculectomy and abdominoplasty. When surgery to remove extensive skin redundancy and fat folds is performed solely to enhance a patients appearance in the absence of any signs or symptoms of functional abnormalities, the procedure should be considered cosmetic in nature. This patients panniculus hangs well below the level of the pubis to at least the mid-thigh. The pannus is thick and heavy, and the patient complains of difficulty ambulating. She has a chronic rash, but this has not been documented to be disabling. The patient has an intertrigal dermatitis underneath her abdominal pannus, but there is no report of failure of appropriate medical treatment of the rash. The provider recommended surgical intervention to alleviate the inability to walk normally. Based on the evidence-based literature, the requested panniculectomy is medically necessary. However, the requested abdominoplasty is not medically necessary for treatment of this patient. The records provided for review demonstrate that a panniculectomy will be adequate to address the patients condition and the additional abdominoplasty is not medically necessary. 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; or (2) to create a normal appearance, to the extent possible. Applied to this patient, the requested abdominoplasty is not reconstructive in nature. A lax abdomen with an abdominal pannus is not a result of a congenital defect, a developmental abnormality, trauma, infection, tumor or disease. The patients pannus is not an abnormal structure of the body. It is a normal structural change that is an accommodative response to gain or loss of body mass. The appearance of the patient is normal and consistent with the gain and loss of weight. Further, an abdominoplasty would not improve the patients function or provide a more than minimal improvement in the patients appearance. All told, the requested panniculectomy is medically necessary, while the requested abdominoplasty is not medically necessary or reconstructive in nature for treatment of this patient. Final Result: The reviewer determined that a portion of the requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. 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 and prospective authorization and coverage for residential substance use disorder treatment level of care. Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.5 criteria for Clinically Managed High-Intensity Residential Services. ASAM criteria focuses on six dimensions to determine the appropriate level of care including: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. For dimension 1, the patients COWS scoring from 10/29/19 showed mild to moderate withdrawal. The patient meets the criterion for dimension 2, as he has insulin dependent diabetes mellitus requiring continuous monitoring. The records support dimension 3 as the patient has comorbid schizophrenia and PTSD. For dimension 4, the patient has demonstrated that he is willing to change, but remains with cravings, anxiety, and mood swings. The provider described the patient as irritable and was not ready to take accountability for his issues. Dimension 5 is satisfied, as the patient has not yet learned coping strategies other than substances to deal with his psychiatric symptoms and requires more time in this structured environment. Finally, dimension 6, the patient has relayed that his primary social contacts continue to use and he has been unable to maintain sobriety in his current social environment. The patient requires further treatment so that he can learn to tolerate his social stressors. The patient requires a safe and stable living environment in order to develop his recovery skills thus qualifying for ASAM Level III treatment, similar to what patient has received at the current residential facility. Given the severity of the patients illness, the residential substance use disorder treatment level of care was and is medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were and 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 psychiatry with expertise in addiction medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for tramadol 50 mg and prednisone 20 mg. The records provided for review that this patients diagnoses include cervical radiculopathy, myofascial pain and migraines. Although tramadol and prednisone may be helpful in the short-term to reduce the pain from these conditions, these agents are not ideal for the management of these conditions. Neuropathic pain medications such as gabapentin, Cymbalta or pregabalin are likely to be more helpful in reducing the patients neuropathic pain. Furthermore, first-line migraine therapies such as triptans and tricyclic antidepressants are considered the standard of care for the management of migraines. Based on a review of the records provided, the patient has not failed treatment with or has a contraindication to these medications. As such, the requested tramadol 50 mg and prednisone 20 mg are not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medications are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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 enrollee is requesting authorization and coverage for the medication, HP Acthar Gel, 80 units twice a week. The enrollee has seronegative rheumatoid arthritis and systemic lupus erythematosus. The enrollee began treatment with prednisone and Plaquenil. Methotrexate and Enbrel were added, with partial benefit. The enrollee has trialed Humira, Cimzia and Actemra without benefit. Methotrexate was discontinued due to gastrointestinal upset. The enrollee was started on Simponi Aria intravenous infusions. She continues to take Plaquenil with significant control of her disease. Her rheumatologist is requesting HP Acthar Gel, 80 units/mL, to treat the enrollees systemic lupus erythematosus. The enrollees rheumatologist indicates corticosteroids are contraindicated in this enrollee due the severe mood disorder side effects and interactions with Lamictal. Acthar gel is composed of adrenocorticotropic hormone. This hormone works by stimulating the production of cortisol. Adrenocorticotropic hormone has not been proven as safer as or more effective than conventional corticosteroids in the medical literature or peer-reviewed journals. Adrenocorticotropic hormone has not been endorsed for the management of any autoimmune condition by the American College of Rheumatology. Adrenocorticotropic hormone is not used routinely, nor is it considered the standard of care. The medical literature indicates Acthar gel has little evidence supporting its use. Review of the record indicates the enrollee has been treated previously with prednisone and plaquenil, with no mention of any side effects with prednisone. A subsequent note indicates the enrollee cannot take prednisone, methylprednisolone, or solumedrol due to contraindications with lamictal and severe mood disorder side effects. There is no documentation in the record of side effects with the previous use of prednisone. Additionally, prednisone/corticosteroids are not contraindicated with Lamictal per prescribing information. The prescribing information for Acthar Gel notes the common adverse reactions are similar to those of corticosteroids, such as fluid retention, alteration in glucose tolerance, elevation in blood pressure, behavioral and mood changes, increased appetite and weight gain. Therefore, if corticosteroids are considered contraindicated due to severe mood disorder, then clearly the same effect could be expected with Acthar gel.                                                          Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollees parent requested authorization and coverage for Relizorb. The enrollee has a history of cystic fibrosis, pancreatic insufficiency, gastroparesis and suboptimal weight gain, despite gastrostomy tube feeding.  The pediatric gastroenterologist indicated that an attempt was previously made to increase Peptamen 1.5 overnight to three cans, but the enrollee began vomiting. His Marinol was increased to twice a day and his weight increased by one and a half pounds. His body mass index increased from four to five percent. The provider indicated he is not a sedation candidate, so he needs maximal medical management of gastroparesis. Relizorb, 12 cartridges, is recommended. The medical literature indicates the Relizorb cartridge is safe and well tolerated, and resulted in increased levels of plasma fatty acids, suggesting overall increased fat absorption. Scientific evidence shows Relizorb is superior to the available pancreatic enzyme replacement products in terms of effectiveness and compatibility with tube feeding. There is sufficient scientific evidence supporting the safety and effectiveness of Relizorb in improving fat absorption in enrollees with pancreatic insufficiency and cystic fibrosis. Therefore, Relizorb is more beneficial and more appropriate than the available alternatives. Final Result: Three of the three reviewers determined that the requested service is likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Two reviewers are board certified in pediatric gastroenterology, one is board certified in gastroenterology and are actively practicing.  All three 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:  The enrollee requested authorization and coverage for Vertiflex device placement at two levels. The enrollee has lumbar spinal stenosis at L3/4 and L4/5, causing bilateral neural foraminal stenosis and continued, long-term use of opiate analgesics. The enrollee has failed non-opioid therapies, including acetaminophen, non-steroidal anti-inflammatory drugs, muscle relaxants, neuropathic agents, epidural steroid injections, facet blocks, and radiofrequency ablation. He reports functional improvement and decreased pain with opioid pharmacotherapy. The enrollees advocate indicates the enrollee has utilized conservative treatment for six months without significant pain relief. Continued conservative treatment is not expected to yield substantive clinical improvement. Review of the record does not support the medical indication as to why the interspinous process spacer devices should be used rather than standard treatment. There is a lack of evidence to support that interspinous spacer devices are superior in efficacy and safety compared to the standard treatment of decompression. Additionally, there is concern the interspinous process spacer devices lead to higher rates of re-operation. Scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome to support this service as likely to be more beneficial than any other standard treatment.Final Result: Two of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in orthopedic surgery and are actively practicing.  All three 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

An enrollee has requested reimbursement for a chromoendoscopy.  Chromoendoscopy has been demonstrated to be superior to standard alternatives for localization of dysplasia in randomized trials. Per the American Society for Gastrointestinal Endoscopy (ASGE) guidelines for inflammatory bowel disease, chromoendoscopy allows better characterization of visible lesions as endoscopically resectable or unresectable, and chromoendoscopy with targeted biopsies is the preferred surveillance technique to maximize dysplasia detection. Per the joint guideline from the ASGE and American Gastroenterological Association (AGA), chromoendoscopy is suggested rather than white-light colonoscopy. When there is evidence of dysplasia, the data support surveillance using chromoendoscopy with high-definition colonoscopy. This patient was found to have dysplasia on biopsies of the colon. She underwent surveillance biopsies for dysplasia with chromoendoscopy, which was consistent the current guidelines. Therefore, the chromoendoscopy was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the chromoendoscopy was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were 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 reviewers 1, 2, and 3 are board certified in internal medicine with subspecialty certification in gastroenterology 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

: An enrollee has requested authorization and coverage for Mydayis 12.5 mg.The current medical evidence supports the requested medication in this clinical setting. Mydayis has been approved by the U.S. Food and Drug Administration for the treatment of ADHD. Mydayis prescribing information notes that the effects of Mydayis may last up to 16 hours. The novel beaded technology of Mydayis allows a more individualized sustained release of the medication. The requested medication, Mydayis 12.5 mg, is appropriate to treat the patients ADHD and has effects that may last up to 16 hours, which is the duration of effect that the patient has been looking for and has not yet been able to achieve with medications thus far. Under these circumstances, the requested medication, Mydayis 12.5 mg, is medically necessary to treat 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 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The enrollees parent is requesting reimbursement for the inpatient psychiatric treatment program level of care. The enrollee has unspecified psychosis and cannabis use disorder. She was admitted to the adolescent locked unit due to increasing anxiety, irritability and paranoid delusions.  She was hearing voices that were scaring her and demonstrated a preoccupation with religion. The family noted she had been sleeping poorly, was irritable, and had demonstrated self-neglect.  A progress note described the enrollee as easily overwhelmed and anxious. Medical records note she was still mumbling and talking to herself, and endorsing suicidal ideation; stating she would be better off dead.  She continued to feel she was being monitored and that people were out to harm her in some way. Medical records show the enrollee was not a threat to herself or others.  She did not require 24-hour nursing.  She was alert and oriented and had no medical problems.  Records noted it was unlikely that care provided only during the day would increase the enrollee's chance of relapse. The Child and Adolescent Level of Care Utilization System (CALOCUS), developed as a collaboration between the American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists, is a level of care assessment tool used by behavioral health managers and clinicians to support accurate level of care recommendations and was used in this review. The enrollees composite CALOCUS score correlates with high intensity community-based services.Final Result: The reviewer determined that the requested service was not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in psychiatry and child and adolescent 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 similar medical condition.