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

Nature of Statutory Criteria/Case Summary:The patient has requested reimbursement for air and associated ground ambulance transportation services. Acute transverse myelitis can cause profound functional impairments, including loss of limb function and loss of bladder and bowel control. Once diagnosed, treatment with immunotherapy, starting with steroids, is warranted to halt the inflammatory process, allowing recovery to commence. Plasmapheresis, aimed at removing humoral factors inciting the myelitis, is warranted when the response to steroids is poor. Recovery from acute transverse myelitis can be protracted and approximately two-thirds of patients sustain moderate to severe degrees of residual disability. Rehabilitation is typically indicated to optimize function in light of the impairments and to mitigate risk of complications, such as pressure injuries and infections. The records provided for review document that this patient sustained acute paraplegia with neurogenic bladder and bowel due to an idiopathic transverse myelitis. He was hospitalized in California, where he received emergency and acute hospital care services. He was medically stabilized and ready for transition to a rehabilitation facility as of late April 2020. Due to the severity and complexity of his deficits and medical needs, as well as the intensity of his rehabilitative needs, he required acute inpatient rehabilitation services. However, the records do not demonstrate that the patient required transfer from California to Illinois for rehabilitation, or that such transfer required ground and air ambulance services. The facility in Chicago was not the closest facility that could have provided appropriate care for the patient. There are multiple appropriate facilities in the northern California area. Notably, San Francisco, which is a major U.S. metropolitan area with multiple major medical and rehabilitation centers, is in close proximity to Folsom, and within the range of ground ambulance transportation. Transfer to an acute inpatient rehabilitation facility in the state of Illinois, instead of in the patients home state of California, was not consistent with current medical literature recommendations. For these reasons, the air and associated ground ambulance transportation services were not medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were 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: The patient has requested authorization and coverage for rhinoplasty. The World Professional Association for Transgender Health (WPATH) lists facial feminization surgery as a medically necessary treatment for gender dysphoria. WPATH notes that for certain patients, an intervention like a reduction rhinoplasty can have a radical and permanent effect on their quality of life. In this case, given that the patient has a diagnosis of gender dysphoria and the provider has recommended facial feminization surgery, the requested service is medically indicated. Therefore, rhinoplasty is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services 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 with expertise in transgender health 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 Euflexxa injections in the left knee. Findings: Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines 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. In this case, the patient has tried and failed other conservative treatments, such as cortisone injections, with the alternative being a total knee arthroplasty Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, Euflexxa injections in the left knee are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.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 Otezla 30 mg. A study notes the severity of psoriasis is generally defined by the total BSA involved, with BSAs of 3% to 10% considered moderate disease. Another study notes therapeutic options for moderate to severe plaque psoriasis include oral phosphodiesterase 4 inhibitors, such as Otezla. In this case, the documentation reflects the patients psoriasis affected 10% of BSA, putting the disease in the moderate category. As such, the requested medication is medically indicated. Therefore, Otezla 30 mg 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 dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transcranial magnetic stimulation (TMS). Based on current peer-reviewed medical literature, the first-line recommendations for the treatment of OCD include selective serotonin-reuptake inhibitors (SSRIs) or clomipramine, and cognitive behavioral therapy. A recent meta-analysis found active repetitive TMS to be clinically and statistically superior to sham treatment. Moreover, researchers reported that protocols targeting the supplementary motor area have been found to be helpful for OCD in multiple randomized controlled trials and meta-analyses. This patient has undergone multiple trials of evidence-based treatment for OCD. The provider reports that the patient has been treated with three SSRIs, clomipramine, and four atypical antipsychotics as well as other psychotropic agents. He also reports having had a trial of cognitive behavioral therapy. For these reasons, the requested TMS is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested TMS is 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 services are likely to be more beneficial for treatment 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 psychiatry and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for rituximab infusions. Zappa and colleagues reported on a case of a patient with antisynthetase syndrome with severe interstitial lung disease (ILD) and acute respiratory failure and found that with infusions of anti-CD20 therapy (rituximab) the patients clinical conditions improved rapidly. Dasa and colleagues performed a review of the literature documenting the treatment of 45 patients with ILD secondary to antisynthetase syndrome. The authors found that rituximab treatment was well tolerated in the majority of cases. Given that rituximab is the standard of care in treating patients with progressive ILD, the requested services are medically indicated. Therefore, rituximab infusions are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in pulmonary disease and critical care 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Orthovisc (hyaluronan) injections series to both knees. Findings:  The physician reviewer found that 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 standard 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 presents with a history of osteoarthritis of both knees primarily involving the patellofemoral joints which has not improved despite arthroscopic debridement and chondroplasties. However, the patient benefitted from viscosupplementation on multiple occasions since 2011. The last series of injections were given in October 2019. In light of the patients recurrent bilateral knee pain, the provider has recommended repeat viscosupplementation with Orthovisc injections. Given the current support in the medical literature, the requested Orthovisc (hyaluronan) injections series to both knees are medically necessary for treatment for 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for surgery (CPT 29914 hip arthroscopy with femoroplasty and CPT 29916 hip arthroscopy with labral repair). This patient presents with ongoing chronic right hip pain with associated swelling, nocturnal pain, and limited range of motion. Significant functional limitations are noted in activities of daily living and ability to work. Clinical examination findings are reportedly consistent with imaging evidence of right gluteus medius with high-grade partial to near complete insertional tear of the greater trochanter and diffuse anterior labral tear. There are documented radiographic findings consistent with femoroacetabular impingement and minimal osteoarthritis, Tonnis grade 1. The provider noted that the patient has failed over six months of comprehensive conservative treatment. Current-evidence based medical literature supports surgical intervention in this patients clinical scenario. In the medical literature, Khan and colleagues concluded that arthroscopic intervention results in improvement in functional outcomes at both the short-term and midterm for patients with symptomatic femoroacetabular impingement in the absence of significant existing degenerative changes. This patients records demonstrate that the patient does not have severe osteoarthritis in the right hip, which could preclude arthroscopic surgery. For these reasons, the requested surgery (CPT 29914 hip arthroscopy with femoroplasty and CPT 29916 hip arthroscopy with labral repair) is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested surgery 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 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 genioplasty with two or more sliding osteotomies and an osteoplasty facial bones augmentation. The World Professional Association for Transgender Health (WPATH) lists facial feminization surgery as a medically necessary treatment for gender dysphoria. WPATH notes that for certain patients, surgical procedures such as facial feminization surgery can have a radical and permanent effect on their quality of life. In this case, the patient has a diagnosis of gender dysphoria and the provider has recommended facial feminization surgery. There is sufficient support for the requested service in this setting. Therefore, genioplasty with two or more sliding osteotomies and an osteoplasty facial bones augmentation are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry with expertise in transgender health 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 (1) Dupixent, (2) Millipred, and (3) Vimpat (lacosamide). Findings:  The physician reviewer found that Seidman and colleagues reported that the addition of dupilumab to the treatment regimen of a patient with refractory bullous pemphigoid resulted in the patients symptoms of pruritus and blistering becoming well-controlled. In this case, the patient has a history of bullous pemphigoid and symptoms of chronic rash for over five years. She has been treated with oral and topical steroids, light box, antihistamines, and multiple medications including gabapentin, dapsone, and prednisone without improvement. Given that the patient has tried and failed multiple therapies, Dupixent is medically indicated as a reasonable next step. Therefore, Dupixent is medically necessary for the treatment of this patient. The records indicated that the patient was being treated for small fiber neuropathy. Given that she had tried and failed lamotrigrine and was on cabemezapine, Vimpat (lacosamide) is medically indicated. Therefore, Vimpat (lacosamide) is medically necessary for the treatment of this patient. Current medical literature does not support the use of Millipred for atopic dermatitis and pruritis. Therefore, Millipred is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medications are partially 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for abatacept (Orencia) infusions to be administered at a pediatric-tailored infusion center associated with a hospital. Current medical literature does not provide specific guidance regarding the administration of IV abatacept at a pediatric outpatient infusion center affiliated with a hospital versus at home, at a doctors office, or at an outpatient infusion center that is not affiliated with the patients primary hospital. Researchers noted that in the treatment of JIA, compared to other biologics, abatacept showed a lower rate of serious adverse events and the lowest rate of infection. In this case, the provider noted concerns regarding the patients MCTD/SLE overlap syndrome creating difficulty in establishing proper IV access and of possible adverse reactions to the infusion. However, infusion therapy notes indicated the patient tolerated IV infusion without complications or reactions. Therefore, abatacept (Orencia) infusions to be administered at a pediatric-tailored infusion center associated with a hospital 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Gelsyn-3 injection series in the right knee. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. 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. In this case, the patient has tried and failed conservative therapies, including corticosteroid injections. Given the patients limited options, with the alternative being total knee arthroplasties, and based on the current medical literature, the requested services are medically indicated. Therefore, Gelsyn-3 injection series in the right knee are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for Saxenda 3 mg pen injector. Based on current peer-reviewed medical literature, this patient does not meet the criteria for treatment with Saxenda for weight loss or treatment of obesity related comorbidities. Per Lee and Dixon, pharmacotherapy can be a useful adjunct to lifestyle intervention in effecting and maintaining clinically meaningful weight loss. The authors noted that long-term pharmacotherapy for weight loss is appropriate for patients with a BMI of 30 kg/m2 or greater, or patients with a BMI of 27-20 kg/m2 with documentation of obesity related complications. The records provided for review demonstrate that this patient has a BMI less than 30 kg/m2. There is a lack of evidence of obesity related comorbidities to support an indication for treatment with Saxenda. Therefore, the Saxenda 3 mg pen injector received, and future Saxenda 3 mg pen injector, was not and is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the medication at issue was not and 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 surgery with subspecialty certification in minimally invasive and bariatric 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.