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

Nature of Statutory Criteria/Case Summary:  An enrollees parent has requested authorization and coverage for Dupixent.Findings: The medical evidence supports the requested medication in this clinical setting. This patient has a diagnosis of atopic dermatitis. Past medications tried and failed include triamcinolone, fluocinonide, Elidel, topical tacrolimus, Eucrisa, and antihistamines. Per the submitted documentation, the patients eczema was not controlled prior to Dupixent. After starting on Dupixent, his symptoms are 70-80% improved and only require the use of topical triamcinolone cream. A study performed a randomized, double-blind, placebo-controlled trials involving adults who had moderate-to-severe atopic dermatitis despite treatment with topical glucocorticoids and calcineurin inhibitors. The authors noted, Dupilumab was evaluated as monotherapy in two 4-week trials and in one 12-week trial and in combination with topical glucocorticoids in another 4-week studyIn the 4-week monotherapy studies, dupilumab resulted in rapid and dose-dependent improvements in clinical indexes, biomarker levels, and the transcriptome. The results of the 12-week study of dupilumab monotherapy reproduced and extended the 4-week findings. The authors concluded, Patients treated with dupilumab had marked and rapid improvement in all the evaluated measures of atopic dermatitis disease activity. This patient has severe uncontrolled atopic dermatitis despite treatments with topical steroids (triamcinolone), topical tacrolimus and antihistamines, and his symptoms have impacted his quality of life. There is sufficient support for the requested medication in this patients case. Therefore, Dupixent 200 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for intravenous immunoglobulin (IVIG) (20 grams every two weeks).Findings:  The physician reviewer found that dysautonomia as an umbrella term referring to any disorder associated with dysfunction of the autonomic nervous system. The authors further note, There are many different mechanisms by which dysautonomia may arise, but there has been increasing evidence and awareness that it may be immune-mediated in some patients. Autoimmune autonomic dysfunction may be peripheral due to an immune-mediated small fiber polyneuropathy (SFPN). SFPN may manifest clinically as postural tachycardia syndrome, orthostatic intolerance, orthostatic hypotension, inappropriate sinus tachycardia, gastrointestinal dysmotility, complex regional pain syndrome, and/or neurogenic bladder. The authors recommend IVIG as a first-line treatment for immune-mediated neuropathies such as Guillain-Barre syndrome, chronic inflammatory demyelinating polyneuropathy, and multifocal motor neuropathy. Based on a retrospective analysis of 38 patients with refractory autoimmune dysautonomias, the authors concluded, There is increasing evidence that IVIG is safe and effective in a subset of patients with autonomic disorders and evidence for autoimmunity. A 4-month IVIG trial should be considered in severely affected patients who are refractory to lifestyle and pharmacological therapies. In this case, the patient has an underlying autonomic nervous system dysfunction that has been refractory to multiple treatments. Given that current medical literature demonstrates clinical improvement in patients with dysautonomia with IVIG treatment, the requested services are medically indicated. Therefore, IVIG (20 grams every two weeks) is 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 neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for body contouring services. The World Professional Association for Transgender Health (WPATH) lists body contouring as a medically necessary treatment for gender dysphoria. WPATH notes that non-genital procedures are routinely performed in the treatment of patients with gender dysphoria and that these surgical interventions are often of greater practical significance in the patients life than reconstruction of the genitals. In this case, the patient has a diagnosis of gender dysphoria and the provider has recommended body contouring services. In this patients case, body contouring services are in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested services are clinically appropriate in terms of type, frequency, extent, site, and duration. The requested services are not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Accordingly, body contouring services are 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 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: The patient has requested authorization and coverage Skyrizi 150 mg syringe (1 mL/84 days). The U.S. Food and Drug Administration (FDA) has approved Skyrizi for the treatment of patients with moderate-to-severe psoriasis and is highly efficacious. Researchers evaluated the safety and efficacy of Skyrizi in comparison to ustekinumab and placebo. The authors concluded that Skyrizi showed superior efficacy to both placebo and ustekinumab in the treatment of moderate-to-severe plaque psoriasis. The records provided for review document that this patient has extensive enough disease to warrant consideration of biologic therapy with a BSA of approximately 10%. There are no step therapy requirements per the American Academy of Dermatology (AAD) and National Psoriasis Foundation (NPF) psoriasis treatment guidelines. Given this support, the requested Skyrizi 150 mg syringe (1 mL/84 days) is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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: Urgent Care
Decision: Upheld Decision of Health Plan

Findings:  The physician reviewer found that An enrollee has requested reimbursement for services.At issue is whether the patient received emergency medical services as defined in Health and Safety Code section 1317.1, subdivision (a)(1). Emergency services and care means medical screening, examination, and evaluation by a physician and surgeon, or, to the extent permitted by applicable law, by other appropriate licensed persons under the supervision of a physician and surgeon, to determine if an emergency medical condition or active labor exists and, if it does, the care, treatment, and surgery, if within the scope of that persons license, necessary to relieve or eliminate the emergency medical condition, within the capability of the facility. Please note that a screening examination in an emergency department, and any medical services received from on-call specialists in the emergency department, are, by definition, an emergency medical service.Per Health and Safety Code section 1317.1.(b), an emergency medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) placing the patients health in serious jeopardy; (2) serious impairment to bodily functions; (3) serious dysfunction of any bodily organ or part.A recommendation for prostatectomy is acceptable for the diagnosis of prostate cancer, especially in the setting of Gleason 3+3=6 disease. In this patients case, however, the records do not document an emergent need for intervention. There is no indication from the submitted records that the patients cancer diagnosis or any other medical issues or complicating factors necessitated emergent care, or that any delay in care beyond the treatment date would pose a practical risk of likelihood of harm to the patient. Therefore, the patient did not receive emergency medical services as defined in Health and Safety Code section 1317.1, subdivision (a)(1). Final Result: The reviewer determined that the services at issue were not emergency medical services as defined by California law. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for sensory nerve response and lower extremity monitoring for legs. The records provided for review document that this patient presented with a significant deformity from congenital scoliosis. The surgery involved resection of vertebrae including close work to the spinal cord at the L1 level. Neural monitoring is appropriate when the anticipated surgical intervention is performed close to the spinal cord. Corrective spinal deformity surgery is a generally accepted indication for intraoperative neural monitoring to prevent reversible neurologic injury from realignment of the spine. The current evidence supports the use of neural monitoring in this patients clinical setting. Therefore, the sensory nerve response and lower extremity monitoring for legs were medically necessary for this patient.  Final Result: The reviewer determined that the services at issue were 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a MitraClip procedure with a one-day hospital inpatient stay. The U.S. Food and Drug Administration (FDA) approves the use of percutaneous mitral valve repair using the MitraClip device for high-risk patients with degenerative or other primary mitral valve regurgitation. Asch and colleagues report that the Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients with Functional Mitral Regurgitation (COAPT) trial demonstrated that patients with 3+ or 4+ mitral regurgitation who remained symptomatic despite maximally tolerated guideline directed medical therapy benefited from MitraClip implantation, regardless of their degree of left ventricle (LV) dysfunction, LV dilatation, pulmonary hypertension, severity of tricuspid regurgitation, or individual mitral regurgitation characteristics. The American Heart Association (AHA) and American College of Cardiology (ACC) guidelines for the management of patients with valvular heart disease recommend the MitraClip treatment for severely symptomatic patients, rated at New York Heart Association (NYHA) class III or class IV, with chronic severe primary mitral regurgitation with favorable anatomy for the repair procedure, a reasonable life expectancy, and prohibitive surgical risk due to severe comorbidities who remained severely symptomatic despite optimal medical therapy. In this case, notes dated 10/6/21 reported that the patient is experiencing severe dyspnea on exertion which is progressive, indicating that the patient has class III heart failure symptoms. Therefore, the requested MitraClip procedure with a one-day hospital inpatient stay is likely to be more beneficial for the treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested MitraClip procedure with a one-day hospital inpatient stay is likely to be more beneficial for the treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested service is likely to be more beneficial for the treatment 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 internal medicine with subspecialty certifications in cardiovascular disease and in clinical cardiac electrophysiology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in cardiology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with sub-specialty certification in cardiovascular disease 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Gel One (CPT J7326). 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 routine 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 has a history of positive results with prior Gel One viscosupplementation injections. Furthermore, the patients available treatment options are limited. The requested Gel One injections into both knees is appropriate for management of the patients bilateral knee osteoarthritis. Therefore, the requested Gel One (CPT J7326) injections are medically necessary 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 Orthovisc weekly injections x 3 in the left 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, patient has tried and failed other conservative treatments. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, Orthovisc weekly injections x 3 in the left knee is 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

Findings:  The physician reviewer found that An enrollee has requested authorization and coverage for Januvia 100 mg tablets once daily. Januvia (sitagliptin) is a member of a family of medications known as dipeptidyl peptidase 4 (DPP-4) inhibitors. These medications stimulate insulin secretion and reduce glucagon secretion in a glucose-dependent manner, both effects contributing to the glucose-lowering activity. This medication typically reduces the hemoglobin Alc level by about 0.60.8%. Januvia is a safe and well-tolerated medication for patients with type 2 diabetes. The current medical evidence supports the requested medication in this clinical setting. Therefore, Januvia 100 mg tablets once daily are 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for repeat bilateral L3-L4 facet joint injections and bilateral sacroiliac joint injections. Findings:  The physician reviewer found that lumbar facet blocks for the treatment of low back pain are increasingly used despite remaining controversial. There is no standardized diagnosis and treatment of facet mediated pain in routine clinical practice and in clinical trials, and there is a paucity of evidence in this area for patients who have previously had lumbar fusion. While facet mediated pain and its treatment remains highly controversial, the best diagnostic is a previous facet injection. In this case, the records note that the patient reported relief from two previous successful injections of the same kind and at the same locations, indicating that the L3 through L4 facets and sacroiliac joints are an important source of the patients pain. Chambers notes that while physiotherapy treatments may be of benefit in improving the longer-term outcomes of patients with chronic low back pain, it is not possible to make generalizations or firm conclusions regarding combination treatment of physiotherapy and injection therapy. While the use of physical therapy or of a home exercise program along with injection therapy may promote a healthy lifestyle, there is no particular data that mandates this particular combination of treatments. In this case, given that the records document relief from previous injections, the requested services are medically indicated. Therefore, repeat bilateral L3-L4 facet joint injections and bilateral sacroiliac joint injections 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 neurological 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 Ajovy 1.5 mL injection once a month. Calcitonin gene-related peptide (CGRP) monoclonal antibodies are biologic agents that have been demonstrated to be effective, safe and well tolerated for the preventive treatment of episodic and chronic migraine in phase 2 and phase 3 randomized, placebocontrolled trials. Urits and colleagues noted that randomized placebo-controlled trials in adults with episodic and chronic migraine validated the effectiveness of fremanezumab as preventive therapy for migraine. In this case, the patient has a history of chronic migraines that did not respond to multiple oral preventative medications. However, the patients migraines improved in severity when treated with Ajovy. Based on the available documentation, this patient meets the American Headache Society (AHS) criteria for initiation of CGRP monoclonal antibody therapy. For these reasons, the requested Ajovy 1.5 mL injection once a month is medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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.