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

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested authorization and coverage for dosage escalation of Entyvio 600 mg infusion every four weeks. Findings:  The physician reviewer found that the patient was treated with Entyvio for inflammatory bowel disease and initially appeared to have a clinical response to dosing every six weeks. Telemedicine notes reported that the patients bowel movements fluctuated from three to four times on a good day, to bad days when she lost count of bowel movements. Notes reported that the patients vedolizumab level was 7.0, and the provider recommended an increased dosage of 600 mg of Entyvio every four weeks. The U.S. Food and Drug Administration (FDA) recommends dosage of Entyvio for patients with ulcerative colitis and Crohns disease at zero, two, and six weeks, and every eight weeks thereafter. Sandborn and colleagues note that the efficacy of vedolizumab, an 47 integrin antibody, in Crohn's disease is unknown. The authors further noted that adverse events were more common with vedolizumab-treated patients with active Crohn's disease than those receiving a placebo. In this clinical setting, there is a lack of current medical literature supporting the requested dosing frequency as safe and effective for treatment of the patient's medical condition. Therefore, dosage escalation of Entyvio to 600 mg infusion every four (4) weeks is not likely to be more beneficial than any other available standard treatment for the patients medical condition.Findings:  Two of the three physician reviewers found the requested dosage escalation of Entyvio to 600 mg infusion every four (4) weeks is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested medication regimen is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for community-based adult services. The records document that this patient has multiple health conditions that require dietary management, lifestyle interventions such as exercise, and compliance with medical treatment, including pharmacotherapy. The provider noted that the patient has adequate cognitive faculties, physical capacity, and resources with respect to her durable medical equipment with use of a home blood pressure cuff and home glucose monitor to manage her medical conditions. The patient is able to manage her basic self-care, instrumental activities of daily living, and mobility in the home and community settings. There is a lack of indication in the records that the patient requires community-based adult services. Although the patients compliance with treatment has been suboptimal, no substantive and marginal difference in her clinical course or outcomes is reasonably expected with the addition of the proposed services over compliantly followed management for her underlying medical conditions. For these reasons, the requested community-based adult services are 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for physical therapy. This patient with cervical radiculopathy has experienced persistent neck pain and other symptoms including headaches and dizziness. She reported some symptomatic improvement and range of motion improvement with formal physical therapy. There is a paucity of high-quality evidence informing treatment for cervical radiculopathy, including the efficacy of exercise and physical therapy interventions such as manual therapy and traction. Current treatment guidelines related to the management of cervical radiculopathy are lacking, while higher quality studies are underway. There is a lack of high grade, evidence-based support for prolonged formal physical therapy in this clinical setting. Treatment should include services in the formal therapy setting until transition to an independent program can be made. However, there is a lack of an indication in the available records that this patient has impairments that preclude full transition to an independent program with exercises and modalities that can be applied independently for further improvement in range of motion and symptomatic management. There is no reasonable expectation that her clinical course or outcomes with further formal therapy would be marginally improved over an independent program. The patients documented exercises in the formal therapy setting can be performed independently or substituted with independent exercise. For palliation, the patient can use topical heat, self-massage techniques, and independently applied electrical stimulation pads. All told, the requested physical therapy 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Prolia (denosumab) injection. Findings: According to the American Association of Clinical Endocrinologists (AACE) and American College of Endocrinology (ACE), Osteoporosis may also be diagnosed in patients with a T-score between -1.0 and -2.5 and increased fracture risk using FRAX. The AACE and ACE guideline further states that, Approved agents with efficacy to reduce hip, nonvertebral, and spine fractures including alendronate, denosumab [Prolia], risedronate and zoledronate are appropriate as initial therapy for most osteoporotic patients with high fracture risk. In this case, the records do not document a history of fragility fractures related to osteoporosis. In addition, the patients bone mineral density T-scores of 0.3 and -1.4 in the lumbar spine and hip, respectively, are not consistent with a diagnosis of osteoporosis. The patients FRAX score is low at 9.1% for a major osteoporotic fracture and 1% for a hip fracture, which is below the recommendations of 20% risk for a future major osteoporotic fracture and 3% for a future hip fracture to support an indication for treatment with Prolia. Based on the available records, the patient does not meet the current criteria for osteoporosis. Given these findings, the requested Prolia (denosumab) injection, 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.
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 injection series in both knees. Findings: This patient presents with bilateral knee osteoarthritis. Treatment has included non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroid injections and physical therapy without substantial benefit. The patients provider noted that the findings on magnetic resonance imaging (MRI) showed a horizontal degenerative tear of the lateral meniscus, articular damage of the lateral tibial plateau, and a small loose body. Physical examination findings noted bilateral positive McMurray signs, bilateral pain with range of motion, and right-sided mild patellofemoral crepitus. Their provider has recommended a series of viscosupplementation with Euflexxa. Evidence from systematic reviews and randomized controlled trials suggests that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it remains unknown which patients are ideal candidates for treatment. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons (AAOS) indicate that the evidence remains inconclusive. As such, the AAOS does not currently support viscosupplementation as standard treatment for osteoarthritis of the knees. In light of the foregoing, viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and when a patients remaining treatment options are limited. In this case, the patients treatment options are limited. The patient has tried and failed conservative modalities with total knee arthroplasty as the remaining alternative. For these reasons, the requested Euflexxa injection series in both knees is medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for monthly Octagam infusions (HCPCS J1568).The submitted documentation supports the medical necessity of the requested services. The Health Plans denial noted that the patient could be tested to see if she makes enough antibodies using certain vaccines. While this patients IgG 1 level is considered borderline low given her age, the IgG 3 level is considered low. The literature demonstrates that individuals with low IgG 1 and IgG 3 levels can be at risk of recurrent sinopulmonary infections even despite normal antibody production in response to vaccinations. Therefore, it would not be appropriate to judge the patients immunodeficiency status on her response to vaccines. Given the history of recurrent pulmonary infections in the setting of these laboratory values, immunoglobulin replacement therapy is medically indicated. Therefore, monthly Octagam infusions (HCPCS J1568) are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary to treat the patient's medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in allergy and immunology 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 Mvasi. Findings:  The physician reviewer found that  for the treatment of metastatic colorectal cancer, with intravenous 5-fluorouracil based chemotherapy for first or second line treatment, or with fluoropyrimidine-irinotecan or fluoropyrimidine-oxaliplatin based chemotherapy for second line treatment in patients who have progressed on a first line bevacizumab product-containing regimen. In this case, the patient has stage IV colon cancer, and has progressed on a combination of oxaliplatin and irinotecan. While single agent therapy may be reasonable, the requested medication is not medically indicated in combination therapy with FOLFOXIRI. Therefore, Mvasi (Q5107) is not medically necessary for the 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 internal medicine with sub-specialty certifications in medical oncology and hematology 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 Xeljanz tablets, 90 per month.Findings: Two out of three physician reviewers found that the requested medication, Xeljanz  tablets, 90 per month, is likely to be more beneficial than any other available standard treatments for the patients medical condition.Alopecia areata is an autoimmune disorder that causes hair loss in the scalp and can progress into alopecia universalis. It has been noted that the higher the percentage of surface involvement, the more aggressive the treatment is. Researchers have published an algorithm that recommends topical and oral steroids with minoxidil, sensitization, JAK inhibitors or prostheses with greater than 50% scalp involvement. Studies show, the consensus for preferred second-line agent was achieved in one of eleven questions. This question was, `[I]f all treatments were equally reimbursed, JAK inhibitors would be the ideal choice of systemic therapy in adults`. In this case, the patient has a longstanding history of alopecia areata and demonstrated alopecia universalis. When Xeljanz treatment was initiated, the patient exhibited significant improvement in scalp and facial hair regrowth. He continued the medication for about one year and then stopped. Upon follow up, the patient complained of more hair loss upon cessation of Xeljanz. The patient has completed and failed topical and oral steroid therapy and has a history of doing well on Xeljanz. Thus, the patient has a history of significant improvement while on Xeljanz, which is now waning after being off of the medication for about three months. Under these circumstances, the requested medication, Xeljanz tablets, 90 per month, is likely to be more beneficial than any other available standard treatments for the patients medical condition.Final Result: The reviewers determined that the requested medication is likely to be more beneficial than any other available standard treatments for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in dermatology 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 a sock butler. Stroke is known to result in severe, chronic functional deficits reducing independence with activities of daily living especially bathing, grooming, and dressing. In some cases, a patient who has sustained a stroke or has another disabling medical condition, can benefit from durable medical equipment that increases their mobility and ability to perform their own self-care tasks. Various types of durable medical equipment should be utilized when appropriate to enhance the patients independence and reduce the burden of care, including the number of hours of formal or informal caregiver assistance provided. Based on the records provided for review, there is a lack of documentation that the patient is physically and safely able to use the requested dressing aide to help don her socks and thereby enhance her independence. Accordingly, the requested sock butler is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested device 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for individual out-of-state counseling services.California Health and Safety Code  1345(h) states that, `Out-of-area coverage  means coverage while an enrollee is anywhere outside the service area of the plan, and shall also include coverage for urgently needed services to prevent serious deterioration of an enrollees health resulting from unforeseen illness or injury for which treatment cannot be delayed until the enrollee returns to the plans service area.`In this case, the patient's mood changes, defiant behavior, and her conflict with her mother were noted to be chronic. The patient had been sent out-of-state by her mother due to concerns about the same behaviors and symptoms that were addressed in outpatient therapy. The patient had been living out-of-state for almost one month prior to starting outpatient psychotherapy there. Records for the patients first counseling appointment state that the patient was referred for difficulties cooperating with rules and respecting her mothers boundaries, for conflict and tension in her relationship with her mother, and for skipping class. The submitted documentation reflects that the patients out-of-state therapist did not report any safety concerns. There was no report of any unsafe behavior or deterioration occurring while the patient was living with her grandparents out-of-state. In addition, no unforeseen illnesses or injuries were noted to have occurred while the patient was out-of-state. Therefore, the individual out-of-state counseling services at issue were not urgent care services, defined as services to prevent serious deterioration of the patients health resulting from unforeseen illness or injury for which treatment cannot be delayed until the patient returns to the Health Plans services area.Final Result: The reviewer determined that the services at issue were not urgent care services. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in psychiatry, with subspecialty certification in 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 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 lumbar transforaminal epidural injection.The submitted documentation supports the medical necessity of the requested service. A systematic review and meta-analysis concluded that lumbar epidural steroid injections were effective. The authors investigated whether epidural injections of steroids produced better clinical effects than local anesthetics or saline for the treatment of lumbosacral disc herniation. Studies noted, Steroid is recommended over local anesthetics or saline for pain control in patients with lumbosacral disc herniation.  Studies noted, For lumbar disc herniation with radiculitisthe evidence is considered good for short-term and long-term relief with local anesthetics with steroids. In this case, the patient has a history of lumbar surgery, and the records document chronic back pain with radiation into the lower extremities. There is sufficient support for the requested service in this clinical setting. Therefore, the requested lumbar transforaminal epidural injection is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary to treat the patient's medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in anesthesiology, with subspecialty 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.