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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Wegovy solution auto-injector 0.25 mg/0.5 ml.Findings:  The physician reviewer found that current medical evidence supports the requested medication in this clinical setting. While lifestyle modification is recommended as the cornerstone of obesity management, many patients do not achieve long-lasting benefits due to difficulty with adherence as well as physiological and neurohormonal adaptation of the body in response to weight loss. There are currently multiple pharmacologic therapies that are available for weight management. Wegovy (semaglutide) is a member of a class of medications known as glucagon-like peptide-1 (GLP-1) analogs. These medications improve glycemic control, reduce body weight and decrease cardiovascular risk. Multiple studies have demonstrated this medications ability to promote weight loss. Therefore, Wegovy solution auto-injector 0.25 mg/0.5 ml 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for hyaluronan injections every six months (right knee). An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet-rich plasma, and other agents to make it more effective. 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, there is a history of significant pain relief from prior viscosupplementation. Oral and topical NSAIDs were not effective. Additionally, the patient reported side effects from corticosteroid injections. Therefore, hyaluronan injections every six months (right knee) are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Findings:  The physician reviewer found that A patient has requested authorization and coverage for whole body PET-CT imaging. At issue is whether the requested whole body PET-CT imaging is medically necessary to treat the patients medical condition. Accurate staging is crucial with patients who have been newly diagnosed with breast cancer, as patients with locally advanced disease are at high risk for distant metastases. For high-risk patients, such as those with multicentric disease or axillary metastases, PET/CT is indicated in the detection of distant metastatic disease, which guides treatment decisions. According to the National Comprehensive Cancer Network (NCCN) clinical practice guidelines, PET/CT is recommended for evaluation of distant metastases in patients starting with stage IIIA. The presence of extra-axillary metastatic lymph nodes or distant metastatic disease determines the stage and therefore management. In this case, the patient is at least stage IIIB due to the tumor extending to the skin. Therefore, PET/CT is medically necessary for staging of the patients disease. Accordingly, the requested whole body PET-CT scan is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Sublocade (300 mg injection once a month). At issue is whether Sublocade (300 mg injection once a month) is medically necessary to treat the enrollees mental health or substance use disorder medically necessary as defined in Health and Safety code section 1374(a)(3)(A) set forth below. Medically necessary treatment of a mental health or substance use disorder means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of that illness, injury, condition, or its symptoms, in a manner that is all of the following: (i) In accordance with the generally accepted standards of mental health and substance use disorder care. (ii) Clinically appropriate in terms of type, frequency, extent, site, and duration. (iii) 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.The submitted documentation does not support the medical necessity of the requested medication. Strain and colleagues report that medication-assisted treatment (MAT), consisting of treatment with an opioid agonist or antagonist and adjunctive psychosocial treatment, is first-line treatment for most patients with an opioid use disorder. Buprenorphine is available in daily transmucosal formulations, as a long-acting six-month implant, and as an extended-release subcutaneous injection. The aim of therapy with long-acting injectable buprenorphine is to address problems with limited adherence, diversion, and misuse of the transmucosal formulation. In this case, the patient declined referral to a methadone clinic for continued treatment of opioid addiction. Given that the records do not document that this patient has failed sublingual Suboxone therapy due to nonadherence, diversion, or misuse, the requested medication is not medically indicated. Sublocade (300 mg injection once a month) is not in accordance with the generally accepted standards of mental health and substance use disorder care. Sublocade (300 mg injection once a month) is not clinically appropriate in terms of type, frequency, extent, site, and duration. Therefore, Sublocade (300 mg injection once a month) 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a wearable cardioverter defibrillator for three months. The wearable cardioverter defibrillator is indicated as a temporary therapy for patients with a high risk for sudden cardiac death (SCD). The American College of Cardiology (ACC), American Heart Association (AHA), and Heart Rhythm Society (HRS) guidelines on the management of patients with ventricular arrhythmias note that patients who may benefit from the temporary use of a wearable cardioverter defibrillator include: patients with a permanent implantable cardioverter-defibrillator (ICD) that must be explanted, or those with a delay in implanting a newly indicated ICD; patients with reduced left ventricular (LV) systolic function [a LV ejection fraction (EF) at or less than 35%] who have undergone coronary revascularization with coronary artery bypass graft (CABG) surgery in the past three months; patients with newly diagnosed nonischemic cardiomyopathy with severely reduced LV systolic function that is potentially reversible. Among patients with reduced LV systolic function who have had a myocardial infarction (MI) within the past 40 days, there is conflicting data on the benefits of a wearable cardioverter defibrillator as a primary prevention against SCD. In this case, the patient does not meet the criteria for patients who may benefit from the temporary use of a wearable cardioverter defibrillator. Therefore, a wearable cardioverter defibrillator for three months was not likely to have been more beneficial for treatment of the patient's condition than any available standard therapy.Findings:  Two of the three physician reviewers found the wearable cardioverter defibrillator for three months at issue was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the device at issue was not likely to have been 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 sub-specialty certifications in cardiovascular disease and in clinical cardiac electrophysiology and is actively practicing. Physician reviewers 2 and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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 reimbursement for computed tomography (CT) scan of the thorax. According to the published guidelines from the American Thyroid Association (ATA), CT thorax is not listed as an indicated imaging diagnostic tool for thyroid nodules. Per the ATA guidelines, an ultrasound was the appropriate imaging modality for evaluation of this patients thyroid nodule. There is a lack of clinical symptoms documented in the records provided to support possible spread of endometrial malignancy to the thyroid.  The treating provider did not indicate the CT was ordered due to any chest related symptoms. Per the position statement from the Society of Gynecologic Oncology (SGO), symptoms or clinical examination findings to support recurrence, spread of disease, or monitoring of active evidence of disease in the chest must be present to support use of CT of thorax. In the absence of documentation of these findings, the CT scan of the thorax was not medically necessary for evaluation of this patient. Final Result: The reviewer determined that the services at issue were not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in obstetrics and gynecology 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: A patient has requested authorization and coverage for Botox (Botulinum Toxin) injections. Findings: At issue is whether Botox (Botulinum Toxin) injections are medically necessary for the treatment of this patient. The current medical evidence supports the requested medication in this clinical setting. An increased number of clinicians have adopted the use of Botox in the management of temporomandibular disorders (TMD) as either a standalone treatment or as an adjunct. A study conducted a systematic review of the relevant literature and concluded that a number of studies have shown promising results that support the use of botulinum toxin in the management of TMD. Another study has also concluded that Botox injections have shown to be safe and effective for treatment for myofascial temporomandibular joint disorder. In this case, the patient is noted to suffer from chronic pain and heavy cramping in her jaw muscles. Records indicate that she has failed NSAIDs, physical therapy and treatment with a bite guard. The patient has previously tried Botox, with significant improvement. As noted above, Botox has been found to be of benefit for the treatment of pain in temporomandibular joint (TMJ) dysfunction patients. Under these circumstances, the requested Botox (Botulinum Toxin) injections are medically necessary for this patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for this patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in otolaryngology, with subspecialty certification in neurotology, 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 Dupixent. Findings: Dupixent is an interleukin-4 (IL-4) receptor alpha antagonist that has been approved by the U.S. Food and Drug Administration (FDA) for the treatment of adult patients with moderate-to-severe atopic dermatitis whose disease is not adequately controlled with topical prescription therapies. There are very few treatments approved for this condition. There is substantial data supporting the use of Dupixent in moderate-to-severe atopic dermatitis (eczema), and this medication has a very favorable side effect profile in comparison to other systemic agents that would be available to this patient. There are no step therapy guidelines in dermatology that recommend protopic or standard oral immunosuppressive therapies for severe eczema prior to Dupixent. Per the submitted documentation, this patient appears to be a good candidate for this treatment. The medical evidence supports the requested medication in this clinical setting. Therefore, Dupixent is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Findings:  The physician reviewer found that The patients parent has requested authorization and coverage for occupational therapy services (twice a week). As noted in the medical literature, patients with ADHD manifest behavioral and functional impairments, as well as social and psychological issues that are problematic for participation and academic learning (Ianni, et al.). Patients in this subset also demonstrate delays or inability to meet expected milestones in different developmental domains. As a result, multidisciplinary team involvement including neuropsychology, occupational and speech therapy, and social work may be required to maximize the patients quality of life. Acquisition of effective motor skills is important to perform language and communication, academic learning, social interaction, and self-care functions. Occupational therapy trains patients to effectively interact with their environment and engage in daily activities. In this patients case, occupational therapy is indicated to  maximize functional independence and participation in the school, home, and community environments. The potential benefits of occupational therapy include stimulation of vocalization and language, improved toleration of touch, sound, vestibular stimuli, as well as improved self-care, safety awareness, and upper extremity motor coordination. The occupational therapy interventions including family centered therapy with adaptation and compensation strategies are the appropriate therapeutic interventions for this patient. Moreover, the requested occupational therapy services are in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. Given these findings, the requested occupational therapy services (twice a week) 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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Findings:  The physician reviewer found that An enrollee has requested authorization and coverage for LINX procedure. Overall, there is a lack of randomized controlled trials with long-term follow-up demonstrating that LINX is safer or more effective than standard surgical anti-reflux procedures for the treatment of patients with GERD. One evidence review concluded that the long-term safety and efficacy of LINX - both alone and in comparison to current GERD therapies - remains to be determined (Sheu and Rattner). Another best-evidence review concluded that long-term comparative outcome data past one year are needed in order to further understand the efficacy of magnetic sphincter augmentation (Skubleny, et al.). The current peer-reviewed medical literature does not support the conclusion that LINX is more likely to be beneficial in this case than standard treatment including surgical fundoplication (Sheu, et al.). Further, the American College of Gastroenterology (ACG) guidelines for the management of reflux disease also state that more evidence is needed before LINX can be recommended (Katz, et al.). For these reasons, the requested LINX procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested LINX procedure 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 services are 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for hyaluronic acid injections of the right knee. Findings:  The physician reviewer found that exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet-rich plasma, and other agents to make it more effective. Guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections and in carefully selected cases where everything else has been tried and the options are limited. In this case, the patient has tried cortisone injections, a knee brace, restriction of activities, and medications, without significant long-term relief. The patients options are limited, with the alternative being a total knee arthroplasty. The patient also has metastatic lung cancer and does not wish to undergo surgery. In light of the patients underlying medical conditions, surgery is not medically recommended. The current medical evidence supports the requested services in this clinical setting. Therefore, the requested hyaluronic acid injections of the right knee are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.