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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Humatrope 24 mg cartridge. The U.S. Food and Drug Administration (FDA) approves the use of Humatrope for the treatment of children with growth hormone deficiency. In this case, the records note that the patient had failed two standard growth hormone provocative tests and displayed a growth velocity Z-score below two standard deviations. In this clinical setting, growth hormone therapy is medically indicated until the patient completes puberty. Given that this patient meets generally accepted diagnostic criteria for growth hormone deficiency, the requested medication is medically indicated. Therefore, Humatrope 24 mg cartridge 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 pediatrics with sub-specialty certification in pediatric endocrinology 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 30 treatments hyperbaric oxygen therapy (HBOT) in a multi-chamber. This patients records document a history of gender affirming surgery with body contouring and fat grafting. The patient underwent treatment with HBOT on various dates. As noted by medical literatures, HBOT is a medical technique which delivers oxygen at ambient pressures to increase the amount of dissolved oxygen in the blood and oxygen distribution to tissues. On review of the available medical literature, HBOT was not medically necessary following the body contouring and fat grafting performed in this patients case. There is insufficient evidence demonstrating improved patient health outcomes with HBOT for patients in the post-operative setting after body contouring and fat grafting procedures. Researchers concluded that HBOT can be effective for patients with compromised skin grafts and skin flaps. This procedure notes and physical examination reports did not document concern for any failed hypoxic skin grafts. Given these findings, the 30 treatments HBOT in a multi-chamber were not medically necessary for 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 not. Credentials/Qualifications: The reviewer is board certified in family medicine with subspecialty certifications in preventive medicine and undersea and hyperbaric medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Ventolin HFA aerosol (Ventolin 90 mcg). Current medical literature, based on randomized and blinded studies, indicates that a generic albuterol inhaler is equivalent, in efficacy and in side effect profile, to the brand name Ventolin inhaler for the treatment of asthma. The U.S. Food and Drug Administration (FDA) states, Any generic medicine must perform the same in the body as the brand-name medicine. It must be the same as a brand-name medicine in dosage, form and route of administration, safety, effectiveness, strength, and labeling (with certain limited exceptions). Therefore, Ventolin HFA aerosol (Ventolin 90 mcg) is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine and 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

Findings:  The physician reviewer found that The patient has requested authorization and coverage for panniculectomy surgery. Per the American Society of Plastic Surgeons (ASPS), a panniculectomy involves the removal of hanging excess skin and fat in a transverse or vertical wedge but does not include muscle plication, neoumbilicoplasty, or flap elevation. Sachs and colleagues noted that, A panniculectomy must meet specific criteria to be medically necessary. The pannus must hang below the level of the pubis and be confirmed with photography. Patients must fail medical treatment of intertrigo for three months. Medical treatment includes good hygiene, topical antifungals, corticosteroids, and antibiotics. The role of panniculectomy is to restore normal function. Patients must maintain a stable weight for at least six months. After bariatric  surgery, patients must maintain a stable weight for at least 18 months, including the most recent six months. Based on the available documentation, this patient meets the ASPS criteria for the requested panniculectomy. The records document that the patient has lost 25% of body weight following bariatric surgery and has maintained this weight loss for several years. The provider documented the presence of a large abdominal pannus, which is demonstrated in the photographs provided for review. The patient complains of an intractable rash under the abdominal pannus. A letter from the provider reports that the patients panniculus has caused chronic intertrigo that consistently recurs over three months despite treatment with appropriate medical therapy with topical nystatin and oral fluconazole over a period of three months. The requested panniculectomy would be performed to help restore function. For these reasons, the requested panniculectomy surgery is 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; or (2) to create a normal appearance, to the extent possible. In this patients case, the abnormal structure of the body was due to loss of weight following bariatric surgery. The requested panniculectomy would be performed to improve function by relief of pain and intractable pruritis under the patients abdominal pannus. Moreover, the requested panniculectomy would create a more than minimal improvement in the patients appearance. Therefore, the requested panniculectomy surgery is reconstructive in nature for this patient. All told, the requested panniculectomy surgery is medically necessary and reconstructive in nature for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary and reconstructive in nature 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 16 home health skilled nursing visits (twice a week for eight weeks). As noted in the medical literature, home health skilled nursing services can help prevent recurrent hospital admissions and frequent use of emergency services in patients who have multiple complications due to chronic illnesses. Skilled nursing services provided at a patients home are indicated when medication management, skin injury, wound care, and/or monitoring of nutrition status are included in the patients care plan. A registered nurse (RN) or a licensed practical nurse (LPN) can provide home health skilled nursing services. Home health nurses provide direct services and teach patients as well as caregivers about patient care. In addition, home health nurses manage, observe, and evaluate a patients care. In this case, the patient would benefit from the requested 16 home health skilled nursing visits to help manage his chronic conditions including diabetes, skin infection, edema, monitoring of blood pressure and mentation as well as medication management. In this clinical setting, the requested 16 home health skilled nursing visits (twice a week for eight weeks) 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 physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for computed tomography (CT) coronary calcification testing. Findings:  The physician reviewer found that Numerous clinical studies have demonstrated that coronary artery calcium scoring using ultrafast cardiac CT can add predictive value in assessing risk of coronary heart disease. In one study, a score of zero was associated with a coronary heart disease risk of 1-6%, while a coronary artery calcium score over 300 was associated with a risk of 13-26% (Budoff, et al.). However, the current clinical studies have not demonstrated that coronary artery calcium scoring adds value in clinical management of asymptomatic patients in whom risk factors are targeted. Mamudu and colleagues examined whether CT coronary calcium scoring in asymptomatic patients might have an effect on behavior modification, risk perception, and medication adherence. The authors found that although CT coronary calcium screening improved medication adherence, the impact of coronary artery calcium screening on behavioral and lifestyle factors, perception of coronary heart disease risk, and psychosocial effects was not statistically significant compared with baseline. Overall, there is insufficient support in the peer-reviewed literature demonstrating a significant benefit of CT of the heart with quantitative evaluation of coronary calcium in guiding optimal clinical management of this patient. Therefore, the requested CT coronary calcification testing is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings: Three of the three physician reviewers found the requested CT coronary calcification testing is not likely to be more beneficial for evaluation 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 evaluation 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 certification in cardiology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in cardiovascular disease and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certifications in cardiovascular disease and clinical cardiac electrophysiology 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 Euflexxa injection series in the left knee. The records provided for review document that this patients pain source is likely due to chondromalacia of patellofemoral joint based on the reported symptoms of anterior knee pain, popping, catching, and clicking, and difficulty getting up from a sitting position, with physical findings of patellar tenderness. The provider noted that the patients conservative treatment has included non-steroidal anti-inflammatory drugs (NSAIDs), an intra-articular corticosteroid injection, and physical therapy. The provider has recommended treatment with Euflexxa. Viscosupplementation with Euflexxa hyaluronic acid has been demonstrated to improve the shock absorption and lubrication properties of the synovial fluid in patients with chondropathy and osteoarthritis. Viscosupplementation has anti-inflammatory, analgesic, and chondroprotective properties that can be beneficial in patients with chondromalacia and osteoarthritis. Hyaluronic acid is known to be effective in the treatment of pain related to patellar chondropathy, as in this patients case. Given this support, the requested Euflexxa injections are appropriate for management of this patients chronic left knee pain due to chondromalacia. Therefore, the requested Euflexxa injection series in the left knee is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for VenaSeal procedure. Findings:  The physician reviewer found that recent studies have introduced data suggesting that VenaSeal is a promising therapeutic option for patients with chronic venous insufficiency (Kolluri, et al.). However, there is a lack of prospective randomized controlled clinical trials demonstrating that VenaSeal is superior to standard available treatment modalities for use in this patient population. Gibson and colleagues found that VenaSeal is as safe as thermal ablation and effective in achieving closure of the incompetent veins. Overall, there remains a lack of reports describing the long-term effects of VenaSeal since this procedure to support its routine use in the management of this patients recannulated left greater saphenous vein (GSV) in the left leg. Current literature recommends re-treatment with ablation therapy for GSV recanalization (Morrison, et al.). For this patient., re-treatment with ablation is likely to be the most efficacious approach to treating recurrent venous insufficiency. All told, the requested VenaSeal 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 VenaSeal 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. Credentials/Qualifications: Physician reviewer 1 is board certified in radiology with subspecialty certifications in diagnostic radiology, vascular, and interventional radiology and is actively practicing. Physician reviewer 2 is board certified in general surgery with subspecialty certification in vascular surgery and is actively practicing. Physician reviewer 3 is board certified in general surgery with subspecialty certification in vascular surgery 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 hydrocodone bitartrate/acetaminophen (Norco) 5-325 mg tablets. The Centers for Disease Control and Prevention (CDC) guidelines report that, Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. The CDC noted further that, If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate. The Federation of State Medical Boards (FSMB) state that, opioid therapy for chronic pain that is not cancer-related, or part of palliative care or end-of-life care, only when non-opioid and non-pharmacological options have not been effective and maintain opioid dosage as low as possible and continue only if clear and objective outcomes are being met. In this case, the patient has a hx of chronic pain due to cervical and lumbar spondylosis as well as osteoarthritis. The records document that the patient has been treated with non-opioid therapy and a joint injection, which have been ineffective. The patient has reportedly failed to follow-up with providers for further adjustment of the treatment plan. The provider did not recommend chronic opioid therapy and noted that the risks outweigh the benefits for this patient. Per the CDC and FSMB recommendations, continued treatment with opioid therapy is not supported for this patient. The patient is a candidate for further treatment with non-opioid therapeutic options. All told, the requested hydrocodone bitartrate/acetaminophen (Norco) 5-325 mg tablets are 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for monthly injection of Ajovy. At issue is whether the requested monthly injection of Ajovy is medically necessary for treatment of this patient. Calcitonin gene-related peptide monoclonal antibodies (CGRP mAbs) are biologic agents that have demonstrated efficacy, safety, and tolerability for the preventive treatment of episodic and chronic migraine in phase 2 and phase 3 randomized, placebocontrolled trials. One of these agents, Ajovy, can be administered every four weeks by subcutaneous injection. Per the American Headache Society (AHS) indications for initiating treatment with CGRP mAbs, this patient meets the criteria for treatment with Ajovy injections. The AHS recommends that after three or six months of treatment, clinicians and patients should reassess the benefits of mAbs and continue treatment only if treatment benefits can be documented. In this case, the patient has a history of chronic migraines that have not responded to oral preventative medication topiramate and Botox. On review of the available documentation, this patient meets the AHS criteria for initiation of CGRP mAbs therapy. The records report that treatment with Ajovy has been effective in decreasing the frequency and severity of this patients migraines. For these reasons, the requested monthly injection of Ajovy 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 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

Findings:  The physician reviewer found that The patient has requested authorization and coverage for Orthovisc injection series (three injections to each knee) given every six months for one year (two series total). 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 long history of viscosupplementation of both knees with beneficial, lasting results making a tremendous improvement in the quality of life. The submitted documentation noted nine knee surgical procedures and chronic knee pain. Based on the records, this patient will benefit from additional viscosupplementation. Therefore, the requested bilateral Orthovisc injection series (three injections to each knee) is medically necessary to treat the patients medical condition. Additionally, the requested bilateral Orthovisc injection series (three injections to each knee) given every six months for one year (two series total) 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.