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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for Verzenio. The records provided for review document that this patient presents with glioblastoma located in the right frontal lobe. The patients providers have recommended treatment with Verzenio, which was started on 11/26/21. The U.S. Food and Drug Administration (FDA) has not approved Verzenio for the treatment of patients with glioblastoma. In addition, the National Comprehensive Cancer Network (NCCN) guidelines do not support the use of Verzenio as safe and effective for management of patients with glioblastoma. Furthermore, data are lacking from phase 3 clinical trials demonstrating improved patient health outcomes with Verzenio as compared to other available therapies. Therefore, Verzenio was not and is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings: Three of the three physician reviewers found the Verzenio was not and 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 medication at issue was not and 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 reviewer 1 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in medical oncology and is actively practicing. Physician reviewer 3 is board certified in medical oncology with subspecialty certifications in hematology and internal medicine and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Findings:  The physician reviewer found that The patient has requested authorization and coverage for power wheelchair, group 2 heavy duty, captains chair, patient weight capacity 301-450 pounds (K0825). The records provided for review indicate that this patient has multiple chronic health conditions. The patients provider has recommended a power wheelchair, with a primary indication of atrial fibrillation. The atrial fibrillation has been noted to be paroxysmal. The patient has been appropriately treated with anticoagulation for cardioembolic stroke prophylaxis, as well as multiple pharmacotherapeutic agents and adjustments for rate control (January, et al.). However, the records do not establish that the patient requires a power mobility device to accomplish the mobility-related activities of daily living. Specifically, the patient reports symptoms with too much walking, but there is no documentation that this symptomatology has been verified to be rapid atrial fibrillation, such as through ambulatory event monitoring. Current recommendations for atrial fibrillation management include aggressive treatment of modifiable risk factors for disease progression, including obstructive sleep apnea, obesity, hyperlipidemia, and physical inactivity (Middeldorp, et al.). Use of a power mobility device in lieu of ambulation is expected to exacerbate the patients obesity and comorbid health conditions. Given these findings, the requested power wheelchair, group 2 heavy duty, captains chair, patient weight capacity 301-450 pounds (K0825) is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested equipment is not medically necessary for treatment of the patients medical condition. 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 patient has requested authorization and coverage for Prolia 60 mg injection. This patient has a history of osteoporosis. In addition, the patient has gastroesophageal reflux disease (GERD), for which she takes omeprazole. The patient was reportedly unable to tolerate treatment with Boniva in the past. The patients provider has recommended treatment with Prolia. The most potent antiresorptive agent is Prolia, a monoclonal antibody to the receptor activator of nuclear factor-kB ligand (RANKL). Hildebrand and Kasi noted that Prolia is a bone anti-resorptive drug used to treat osteoporosis and other bone-related disorders. In a large, randomized placebo-controlled trial of 7,868 postmenopausal women with osteoporosis, biannual 60 mg subcutaneous Prolia increased bone mineral density by 9.2% in the spine and 6.0% in the hip when compared to placebo (Lorentzon, et al.). Prolia is indicated as therapy for postmenopausal female patients with osteoporosis at high risk for fracture, defined as patients with multiple risk factors for fracture, a known history of an osteoporotic fracture, or those who have failed prior osteoporosis treatment. Given these findings, the requested Prolia 60 mg injection 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 internal medicine with subspecialty certification in endocrinology, diabetes, and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested authorization and coverage for Dupixent (dupilumab subcutaneous solution pen-injector 300 mg/2 mL). Findings:  The physician reviewer found that  alopecia areata is a common form of immune-mediated alopecia and that current treatment options mostly include non-specific broad immunosuppressants that are administered either locally or systemically, with first-line therapies involving the use of intralesional and topical steroids. However, such therapies are only approved for short-term use due to side effects. The authors further note that immunosuppressive agents such as methotrexate, cyclosporine, and azathioprine lack adequate evidence from randomized controlled studies to support their use and therefore tend to require very close patient follow-up due to potentially severe immunosuppression that may result. The authors explain that contact immunotherapy involving the use of squaric acid dibutyl ester and diphenylcyclopropenone has produced inconsistent results. Dillon reports that although several therapies for alopecia areata have been developed and tested, there is no specific treatment that has been approved, leading to the availability of many off-label conventional treatment options, with very limited responses, including the emerging use of Janus kinase (JAK) inhibitors. Cho and colleagues report a small but growing body of literature supporting the use of dupilumab as an effective treatment option for alopecia areata among a subset of patients with atopic dermatitis. In this case, notes reported that the patient had failed all first, second, and third line therapies including topical corticosteroids, intralesional steroids, tofacitinib, methotrexate, and prednisone. The records note that the patient is achieving improvement in her alopecia as well as her atopic dermatitis on dupilumab. Therefore, Dupixent (dupilumab subcutaneous solution pen-injector 300 mg/2 mL) is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested Dupixent (dupilumab subcutaneous solution pen-injector 300 mg/2 mL) 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 medication is 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 dermatology 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 a FreeStyle Libre 14-day continuous glucose monitoring (CGM) system, including sensors and reader. Medical literature shows that glycemic variability is an integral component of glucose homeostasis for the management of type 2 diabetes. Researchers note that CGM systems may be clinically valuable due to their accuracy and convenience and may promote glycemic and weight control, helping to reduce the risk of hypoglycemia and hyperglycemia. The authors further note that CGMs are a useful tool for real-time monitoring of blood glucose and for assessing the impact of treatment and lifestyle on daily changes in blood glucose levels. Given that current medical literature supports the safety, efficacy, and accuracy of CGMs, the supplies at issue were and are medically indicated. Therefore, a FreeStyle Libre 14-day CGM system, including sensors and reader, is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment and supplies 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 endocrinology, diabetes and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Findings:  The physician reviewer found that The patient has requested authorization and coverage for OneTouch Verio test strips (six to seven test strips daily/30 day supply). Heinemann and colleagues report that self-monitoring of blood glucose (SMBG) allows patients with diabetes to monitor glycemic control. Schnell and colleagues note that the benefits of SMBG in management of type 2 diabetes are supported by randomized and prospective clinical trials, published reviews, meta-analyses, and guidelines. Gribovschi explains that SMBG before and after meals with a glucometer is an important adjunct for achieving and maintaining optimal glycemic control. The use of insulin may support the need for more frequent testing. In this case, the patients medications include oral antidiabetic drugs, rather than insulin, and the prescription directs testing with one strip two times daily, rather than the six to seven times as the patient has requested.  Therefore, OneTouch Verio test strips (six to seven test strips daily/30 day supply) are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested supplies are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
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 Absorica LD. The records provided for review document that this patients acne vulgaris has failed to substantially improve despite treatment with minocycline. Thus, treatment with systemic isotretinoin is a reasonable option for the patient. Treatment of acne follows a stepwise escalation, with isotretinoin being one of the more effective systemic treatments (Eichenfeld, et al.). However, the records fail to support treatment with Absorica LD in lieu of another formulation of isotretinoin. Absorica LD is a micronized formulation of isotretinoin. On review of the medical literature, there is a lack of comparative studies demonstrating superior efficacy of Absorica LD rather than other preparations in the treatment of patients with acne vulgaris. Moreover, this patients records do not document adequate trial and failure, or intolerance to, treatment with a non-lidose, non-micronized formulation of isotretinoin. For these reasons, the requested Absorica LD 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 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 patient has requested reimbursement for residential treatment center (RTC) services. The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. With regard to risk of harm, the records support a score of 2. The patient had some potential for risk of harm due to a history of self-harm. The records did not note current suicidal ideation or significant distress. In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment due to ongoing, variably severe deficits in function. With regard to comorbidity, the records support a score of 2. The patient had minor comorbidity due to a history of cannabis use. In terms of level of stress of the recovery environment, the records support a score of 2.  The patient had a mildly stressful environment as the patient did well in protected environment but was facing some transitions. With regard to level of support of the recovery environment, the records support a score of 2 as the patients parents are supportive and participatory in treatment. In terms of resiliency and treatment history, the records support a score of 2. The patient had a significant response to intensive treatment but was not always able to sustain gains made.With regard to treatment acceptance and engagement, the records support a score of 2. The patient had a positive attitude toward treatment and recovery.Thus, the patient has a total score of 15. In this case, the recommended level of care is low intensity community-based treatment. In this patients case, RTC level of care was not in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were not clinically appropriate in terms of type, frequency, extent, site, and duration. Therefore, RTC services were not medically necessary for the 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 psychiatry with sub-specialty certification in addiction 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: Upheld Decision of Health Plan

Findings:  The physician reviewer found that The patients parent has requested authorization and coverage for infusion J1745 Remicade 10 mg/kg (600 mg) every six weeks. Bauman and colleagues note that many pediatric patients with inflammatory bowel disease (IBD) lose response to infliximab (Remicade) within the first year, and achieving a minimal target infliximab trough concentration is associated with higher remission rates and longer durability. Low infliximab troughs increase the likelihood of loss of response and of increased IBD activity. Children with moderate-to-severe ulcerative colitis are at risk of low trough levels due to increased intestinal losses. In this case, the records note that the patient was treated with a high dose infliximab of 10 mg/kg, rather than the standard dosing of 5 mg/kg. The records show that the patient appears to have had a good response to this induction treatment, documenting an infliximab trough of 10 g/g at seven weeks following the previous dose, indicating that the high dose of 10 mg/kg was not excessive. Calprotectin had also normalized. Although a letter from the patients gastroenterologist referred to breakthrough symptoms, these were not apparent in clinical notes. Given that the patient does not appear to have signs or symptoms of a loss of treatment response, the requested increased dosing frequency of infliximab is not medically indicated. Therefore, infusion J1745 Remicade 10 mg/kg (600 mg) every six weeks is 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Findings:  The physician reviewer found that The patient has requested reimbursement for abdominal wall reconstruction surgery. Emanuelsson and colleagues state, Functional disability related to midline bulging of the abdominal wall is a common complaint in women after childbirth. Abdominal rectus diastasis (ARD) is a sequela of the expansion of the abdominal contents during pregnancy. Massive weight loss and/or congenital disproportion of the collagen III/I ratio may also result in ARD. The authors found no consensus on whether ARD should be considered a pathologic condition requiring operative attention. Strigard and colleagues state, The clinical significance of abdominal rectus diastasis (ARD) is debatable. Even though there are several studies indicating that weak abdominal integrity because of ARD causes symptoms of pain and weakness of the abdominal wall and a decreased quality of life, there are still authors who claim that ARD is just an aesthetic issue. Conclusive studies on the relationship between subjective symptoms and the width of ARD are lacking. Given the lack of conclusive studies on the relationship between subjective symptoms and the width of ARD, the abdominal wall reconstruction surgery performed on 9/8/21 was not medically necessary for treatment of this patient. The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; (2) to create a normal appearance, to the extent possible. In this case, the large diastasis rectus constitutes an abnormal structure of the body caused by trauma from both pregnancy and recent abdominal wall injury. The patient reports significant disability as a result of the rectus diastasis, and the purpose of the surgical repair was to improve function by reestablishing the normal position and function of the rectus abdominus muscles. Thus, the abdominal wall reconstruction surgery performed on 9/8/21 was reconstructive in nature for this patient. Final Result: The reviewer determined that the service was not medically necessary for treatment of the patients medical condition, but was reconstructive in nature. Therefore, the Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Findings:  The physician reviewer found that An enrollee has requested reimbursement for advanced lipoprotein testing (CPT 83704, 82172, 83695, 83698). Overall, there is insufficient support in current medical literature demonstrating a significant benefit of advanced lipoprotein testing in guiding the optimal management of this patients hyperlipidemia in the setting of a strong family history of hypercholesterolemia and premature coronary artery disease.  Low-density lipoprotein (LDL) particle size and concentration are known to be important predictors of cardiovascular disease, but the clinical value of lipoprotein testing remains the subject of clinical study. Mach and colleagues report that disadvantages of testing for cholesterol-rich apolipoprotein (Apo) B include that it has not been evaluated as a primary treatment target in clinical trials, is not included in algorithms for calculation of global risk and has not been a predefined treatment target in controlled trials. While Arsenault and colleagues note that there is an association to elevated lipoprotein (a) levels and increased risk for adverse health outcomes, the clinical utility of the service at issue above and beyond that of a basic lipid panel continues to be inconclusive. Therefore, advanced lipoprotein testing (CPT 83704, 82172, 83695, 83698) was not likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the advanced lipoprotein testing (CPT 83704, 82172, 83695, 83698) at issue was not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.