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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a magnetic resonance neurography (MRI pelvis, 72197, MRI spinal 72158). One newer magnetic resonance imaging (MRI) sequence, magnetic resonance neurography, has emerged extending the range of conventional MRI techniques. The advanced sequences are able to provide detailed information, including the course and function of individual neural fascicles. These data are utilized to tailor a suitable surgical procedure, reducing the risks of postoperative neurological deficit. This patient presented with a left sciatic nerve sheath tumor. The provider recommended evaluation with magnetic resonance neurography to locate the fibers of the sciatic nerve in preparation for surgery. Given the value of this technique, the magnetic resonance neurography (MRI pelvis, 72197, MRI spinal 72158) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the magnetic resonance neurography (MRI pelvis, 72197, MRI spinal 72158) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in neurological surgery 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 phenazopyridine 200 mg. The Health Plan has denied the request and reported the requested medication is not medically necessary for the treatment of this patient. The Health Plan offered phenazopyridine 95 mg or 97.5 mg as an alternative. At issue in this case is whether phenazopyridine 200 mg is medically necessary for the treatment of the patients medical condition. The American Urological Association reports that in UTI, acute-onset symptoms attributable to the urinary tract typically include dysuria in conjunction with variable degrees of increased urinary urgency and frequency, hematuria, and new or worsening incontinence. Shore and colleagues reported that phenazopyridine is a urinary tract analgesic indicated for short-term treatment of irritation in the lower urinary tract. Despite the lack of evidence for extended use, it is often used in varying durations for supportive care for cancer patients with radiation-induced cystitis. Shore and colleagues also noted that phenazopyridine was most commonly prescribed as 100-200 mg three times daily and the study results showed that in doses as high as 200 mg, there were no significant safety issues with uses longer than 14 days. Phenazopyridine 200 mg three times daily is a common dosage used in interstitial cystitis. Lower doses may be appropriate in primarily infectious cystitis. In this case, the patients chronic dysuria is consistent with radiation cystitis. The medical evidence supports the requested medication dosage in this clinical setting. Therefore, phenazopyridine 200 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 urology 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 lumbar/sacral facet joint radiofrequency neurolysis. Medical literature reported that the evidence for therapeutic facet joint interventions is good for conventional radiofrequency. In addition, Lee and colleagues found there was a reduction in pain 12 months post procedure for patients with facet joint disease of the lumbar spine. Moreover, Researchers concluded that RFA of the medial branch nerves for facet-mediated low back pain demonstrates clinical benefit for 6-12 months and possibly up to two years. In this case, the patient has had a diagnostic medial branch block, which provided 80-90% relief for 24 hours before the pain returned. Based on the current guidelines, a positive response to one or two medial branch blocks, with at least 70% pain relief and/or improved ability to function for a minimal duration at least equal to that of the local anesthetic is required to proceed with RFA. However, more recent well-conducted systemic reviews have validated the benefit of RFA for facet arthropathy, as in this patients case. Based on the medical records available for review, the requested lumbar/sacral facet joint radiofrequency neurolysis 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 anesthesiology with subspecialty certification in pain management 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 multiple trigger point injections every two weeks. The European League Against Rheumatism (EULAR) guidelines on the management of fibromyalgia include the strongest recommendations for aerobic and resistance training exercise along with cognitive behavior therapy. These non-pharmacological interventions have the best evidence to support their use in a multi-modal treatment plan. The EULAR guidelines do not recommend or mention regular trigger point injections as part of balanced treatment plan. The records provided for review document that this patients fibromyalgia symptoms have responded well to trigger point injections. However, ongoing repeated injections are not supported in the medical literature for use in this clinical setting. Trigger point injections typically consist of local anesthetic and sometimes corticosteroids, which can cause long-term harm in patients exposed to them repeatedly. Local anesthetics are toxic to the muscles that are injected, and prolonged exposure can degrade the tissue and predispose to further injuries. Treatment with corticosteroids can lead to variety of problems, including osteoporosis, weight gain, and endocrine problems. Based on the information available for review and the most recent evidence based reviews of trigger points and guidelines, the requested multiple trigger point injections every two weeks 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 anesthesiology with subspecialty certification in pain management 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 Xeljanz 5 mg BID (twice daily). Alopecia areata is a chronic immunological disorder characterized by round or oval patches of non-scarring hair loss. Alopecia universalis is a form of alopecia areata that includes eyebrows, eyelashes and facial hair. Treatment focuses on the regrowth of hair. Onset of alopecia areata can have a negative effect on a patients self-esteem, body image, and self-confidence. The experience of alopecia is psychologically harmful and can lead to personal and social problems. Xeljanz is an oral Janus kinase (JAK) 1/3 inhibitor that has been U.S. Food and Drug Administration (FDA) approved for the treatment of moderate to severe rheumatoid arthritis. Studies have also evaluated Xeljanz for treatment of psoriasis, inflammatory bowel disease, and other immunological diseases. Several recent reports in the literature provide evidence for the effectiveness of Xeljanz in the treatment of alopecia areata (Jabbari, et al.; Anzengruber, et al.; Xing, et al.). This patient presents with alopecia areata that has been resistant to multiple standard medical therapies. Given the support in the medical literature, Xeljanz 5 mg BID (twice daily) 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 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

 The enrollee requested reimbursement for the gene test, Prothrombin G20210A (Factor II) mutation testing. The enrollee has a past medical history of a right acoustic neuroma, that was surgically resected. She has a history of migraines, which worsened after pregnancy. The enrollee previously utilized hormonal therapy for her migraines. A magnetic resonance venography (MRV) of the head showed filling defects in the right sigmoid sinus, concerning for thrombosis. Her neurologist recommended further evaluation in the neurointerventional radiology clinic. Hypercoagulable labs were drawn and the treatment plan included an angiogram and lumbar puncture to determine the severity and amount of clot/clots in her brain. However, her physician believed if the enrollee had a clotting disorder, these invasive tests, which carry risk of death, would be potentially unnecessary. The enrollee could avoid these tests and be placed on blood thinners to treat the clots.    Hypercoagulable states can be defined as a group of inherited or acquired conditions associated with a predisposition to venous thrombosis, arterial thrombosis, or both. Venous thromboembolism (VTE) disease is the most common clinical manifestation resulting from hypercoagulable states. There are no tests for a number of inherited conditions and there are no accepted guidelines as to what constitutes indications for such testing. Based on the medical literature, cerebral venous thrombosis is a rare thrombotic condition commonly associated with the presence of thrombophilia, and prothrombin G20210A is one of the most common thrombophilias associated with venous thrombosis. The physician reviewer found that  enrollee with unprovoked VTE and low bleeding risk is planning to stop anticoagulation, providers should test for thrombophilia if the test results would change this decision. In this case, the treatment plan included a decision as to whether or not to proceed with the more invasive testing, including angiogram and lumbar puncture depending on the result of the hypercoagulable test (whether or not enrollee has positive mutation on the Prothrombin G20210A). Considering this unusual site for venous thromboembolism, the enrollee is at a higher risk for serious complications than if it were a deep venous thrombosis of the legs. Thus, it is important for the enrollee and provider to have adequate clinical information to weigh the risks and benefits, and for the enrollee to provide informed consent for further management. The enrollees clinical situation is very suggestive of a genetic component, based on age and the unusual location of clotting. If a genetic condition is diagnosed, treatment decisions may be made accordingly. Final Result: Two of the three reviewers determined that the requested service was likely to have been more beneficial than any available standard therapy for treatment of the enrollees medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient has requested authorization and coverage for weight loss surgery (endoscopic bariatric surgery). Current medical literature does not support endoscopic pouch reduction as a durable treatment for morbid obesity. Overall, the durability of the requested procedure has not been consistently documented in published studies. Although some patients report short-term weight loss, there is a paucity of high-level data demonstrating long-term patient health outcomes. With regard to this patient, the records document prior Roux-en-Y gastric bypass. The patient was able to maintain his weight loss for several years. The provider reports that this patient has gastric pouch enlargement. The physician reviewer found that  endoscopic treatments for this condition have not been shown to result in weight loss for more than three years. By adopting dietary recommendations, the patient was able to lose nine pounds in one week. Given these findings, the requested weight loss surgery (endoscopic bariatric surgery) 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Humira, inject 160 mg (two pens) subcutaneously on day one, then inject 80 mg (one pen) subcutaneously on day 15, then start maintenance inject 40 mg (one pen) every other week. The records provided for review document that this patients symptoms and colonoscopy findings are consistent with moderate-to-severe Crohns disease. The American College of Gastroenterology (ACG) supports treatment with anti-tumor necrosis factor (TNF) medications such as Humira for the treatment of Crohns disease (Talley, et al.; Lichtenstein, et al.). Alternatives such as mesalamine are no longer recommended for primary therapy of Crohns disease, and corticosteroids are not appropriate for long-term primary therapy of Crohns disease. Immunosuppressants are unlikely to be effective for approximately 17 weeks, and are not recommended as monotherapy for induction of disease control in moderate to severe disease (Terdiman, et al.). Corticosteroids, mesalamine, methotrexate, and antibiotics are not appropriate long-term primary therapy for moderate-to-severe Crohns disease. Lack of treatment may result in worsening loss of disease control and complications. The dosing regimen requested is the U.S. Food and Drug Administration (FDA) approved dosing regimen for initiation of Humira. For these reasons, Humira at the dosing requested Humira injection 160 mg (two pens) subcutaneously on day one, then 80 mg (one pen) subcutaneously on day 15, then maintenance Humira 40 mg injection (one pen) every other week) is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication regimen 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 gastroenterology 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 Corrective flap reconstruction surgery for the neck. The researcher noted that in correction of the web neck the lateral approach associated with an advanced flap and a Z-plasty is an effective technique for correction of this neck deformity. The researcher and colleagues noted that, the choice of a surgical technique depends on the size of the skin folds, location of the hairline and the presence of bands of connective tissue. The lateral approach with a shift of glabrous skin flap to the back allows for effective reduction of the webbed neck, excision of bands of connective tissue and correction of the low hairline on the side of the neck. Z-plasty enables an adequate extension of scars and improves the contour of the neck. The decision for the surgical approach with Z-plasty is supported by current peer-reviewed medical literature. Z-plasty scars on the neck can become wide and hypertrophic, and treatment of the scars by nonsurgical modalities or by surgical revision is common. The timing of scar maturation is such that surgical scar revision is generally delayed for at least six months to allow maturation of wound healing. This patient underwent neck scar revision following surgery. The requested surgery is not medically necessary for the patients medical condition given the time that has elapsed since the recent revision procedure. The California Reconstructive Surgery Statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; or (2) to create a normal appearance, to the extent possible. Neck webbing is an abnormal structure of the body caused by the congenital defect of Noonan syndrome. Surgical revision performed would not improve function or create a normal appearance, to the extent possible. Revisionary surgery before adequate wound maturation is likely to heal incorrectly. Another corrective flap procedure would be premature. Moreover, the requested procedure is not expected to provide a more than minimal improvement in the patients appearance. Final Result: The reviewer determined that the requested services are not medically necessary or reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xifaxan. The American College of Gastroenterology (ACG) guidelines recommend Xifaxan for the treatment of IBS-D based on safety and high efficacy in clinical studies. In addition, the U.S. Food and Drug Administration (FDA) has approved Xifaxan for the treatment of IBS-D. Clinical studies have reported positive health outcomes with Xifaxan for patients with IBS-D. The documentation supports that this patient has IBS-D. Treatment with alternative therapies has been unsuccessful. The quantity and duration requested is appropriate and consistent with the FDA approval. For these reasons, the requested Xifaxan 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 internal medicine with subspecialty certification in gastroenterology 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: Upheld Decision of Health Plan

The enrollee requested reimbursement for GeneSight Psychotropic genetic testing. The enrollee has a diagnosis of major depressive disorder who underwent GeneSight Psychotropic genetic testing as ordered by his psychiatrist. The enrollee indicates he has a long well documented history of depression. Over the years he has tried several treatments and medications. The enrollees psychiatrist prescribed this blood test to assist with finding the best medication treatment plan to assist with severe depression. A review of the literature regarding the GeneSight pharmacogenomic testing noted all studies were conducted in the United States, and all studies had a conflict of interest, with authors employed by the manufacturer of GeneSight. Additionally, there was a safety communication warning against the use of many pharmacogenomic tests with the statement of awareness of genetic tests that claim results can be used to help physicians identify which antidepressant medication would have increased effectiveness or side effects compared to other antidepressant medications. The quality medical studies on this type of test have not clearly shown clinical improvements, safety or long-term health benefits compared with standard treatment and services. More independent research related to the effectiveness and utility of pharmacogenetic tools in real world practice is needed, particularly within the primary care setting, where the majority of patients with depression are diagnosed and treated.Final Result: Three of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Therefore, the health plans denial is upheld.Credentials/Qualifications: Three reviewers are board certified in psychiatry and are actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.