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 seven treatments with Sclerosing injections. Findings:  The physician reviewer found that There is long-established research that supports that alcohol sclerosing injections are a viable option in the treatment of intermetatarsal neuroma. Hughes and colleagues conducted a clinical trial in which 101 patients with Mortons neuroma received an average of 4.1 treatments of sonographically guided alcohol injections into the lesion. Partial or total symptom improvement was reported by 94% of the patients. They concluded that alcohol injection of Morton's neuroma has a high success rate and is well tolerated. These statistics are comparable to more established local cortisone injection treatments. While surgical excision of neuromas has long been thought to be more definitive, a retrospective review performed by Kasparek and Schneider found that following surgical treatment of Mortons neuroma, patients reported surprisingly low success rates with 44.9% of patients reporting excellent results and 31.6% of patients reporting good results. The evidence supports that alcohol sclerosing injections for intermetatarsal neuromas are significantly beneficial and a viable alternative that may be preferable to surgery. In this case, sclerosing injections were supported by research and they constituted a conservative treatment option that allowed the patient to avoid the disability and increased risk of complications that comes with surgery. The patient also reported significant relief from this treatment. Under these circumstances, the Sclerosing injections at issue (CPT-64632) were likely to be more beneficial than any other available standard treatments for the patients medical condition.Findings: Two out of three physician reviewers found that the Sclerosing injections at issue (CPT-64632) were likely to be more beneficial than any other available standard treatments for the patients medical condition.Credentials/Qualifications: Physician reviewer 1 is board certified in foot surgery and is actively practicing. Physician reviewers 2 and 3 are board certified in foot and ankle surgery and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and are 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 Tymlos pen injector. Findings: According to the American Association of Clinical Endocrinologists (AACE) and the American College of Endocrinology (ACE), Tymlos is considered an anabolic agent that has been shown in randomized controlled clinical trials to increase bone mineral density and reduce the risk of vertebral and nonvertebral fractures in patients with osteoporosis. Tymlos has been approved by the U.S. Food and Drug Administration (FDA) for the initial treatment of women with postmenopausal osteoporosis who are at high-risk of fracture or have failed or been intolerant of previous osteoporosis therapy. In this case, the patient has demonstrated a progressive worsening of T scores on DEXA scans over a period of several years despite prior therapy with alendronate and zoledronic acid. According to the AACE and ACE guideline, Tymlos is supported for treatment of patients who have failed previous osteoporosis therapy. Given this support, the requested Tymlos pen injector 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 rheumatology 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 lumbar total disc arthroplasty. Findings:  The physician reviewer found that approves for the PRODISC-L total disc replacement for spinal arthroplasty in skeletally mature patients with degenerative disc disease (DDD) at one level from L3 to S1. The patient should have no more than grade 1 spondylolisthesis at the involved level and have failed at least six months of conservative treatment. Contraindications include active systemic or site infection, osteopenia or osteoporosis, bony lumbar spinal stenosis, isolated radicular compression syndromes especially due to disc herniation, and pars defect. In a follow-up at the five-year mark of 236 patients who underwent either ProDisc-L total disc replacement (TDR) or fusions, Zigler and colleagues noted that the TDR group had significantly better improvement on some scales, and while TDR patients avoid the stiffness of fusion and are more satisfied than fusion patients, both fusion and TDR were reasonable surgical options in this specific patient population. In this case, the patient is being treated for lumbar arthralgia and lumbar radiculopathy and reports persistent and ongoing pain. Diagnostic imaging corroborates multi-level degenerative changes with plausible pain generators. In this clinical setting of multilevel degenerative disc disease, the requested service is not medically indicated. Therefore, a lumbar total disc arthroplasty is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has authorization and coverage for custom orthotic inserts.Orthotics have long been utilized to help correct abnormal biomechanics of the foot, alleviating stress and strain from certain muscles, tendons, and ligaments. The medical records document that this patient has painful posterior tibial tendon dysfunction. The patient is noted to have failed conservative treatments, including pain medication, casting, and activity modification. The patient is noted to have calcaneal valgus upon stance and ambulation with foot images provided in the chart notes that demonstrate significant loss of medial column, calcaneal valgus, and prominence of the navicular tuberosity medially. In this particular case, custom functional orthotics are recommended for the treatment of calcaneal valgus and posterior tibial tendon dysfunction. These devices will allow the patient to ambulate in a more neutral position, reducing calcaneal valgus, and alleviating pain and strain from the posterior tibial tendon insertion. For these reasons, the requested custom orthotic inserts are medically necessary for the treatment of the patients medical condition. Final Result: The reviewer determined that the requested equipment 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 podiatry 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 40 hours per week of home skilled nursing services. In a study of 33 families of children with life-limiting diseases requiring an average of five different life-supporting medical appliances, researchers noted that parents spent an average of nine hours daily on caregiving, with the most time-consuming daily needs being feeding and support when the child woke up at night. Current data shows that the number of medical appliances is correlated proportionally with a greater amount of time needed for the childs care. Researchers note that extraordinary and diverse needs are common among family caregivers of medically complex children with special health care needs and that enhanced care coordination support, respite care, and direct home care may address the burdens and unmet needs of these families. While appropriate daily support is important, in this case, the records do not document multiple chronic conditions or life limiting diseases that make this patient dependent on skilled caregivers and the use of complex medical appliances. The records do not reflect that the patient requires highly complex medical care at home or requires several procedures that have to be expertly managed. In this clinical setting, while there is a daily burden of care on the caregivers, the requested services are not medically indicated. Therefore, 40 hours per week of home skilled nursing services are not medically necessary to prevent disease, disability, and other health conditions or their progression.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 physical medicine and rehabilitation with sub-specialty certification in pediatric rehabilitation 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for balloon sinuplasty. The American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) clinical practice guideline defines chronic rhinosinusitis (CRS) as the presence of two or more symptoms, including mucopurulent drainage, nasal obstruction, facial pain/pressure/fullness, or decreased sense of smell, plus inflammation that is documented by mucus or edema in the middle meatus or anterior ethmoid region, sinonasal polyps, and/or radiographic imaging showing paranasal sinus inflammation lasting more than 12 weeks. Piccirillo and colleagues note, Balloon dilation is not appropriate for patients with sinonasal symptoms and a computed tomography (CT) that does not show evidence of sinonasal disease. In this case, CT of the sinus reported normal frontal sinuses without significant mucosal thickening or fluid, patent frontal recesses, and no anomalous frontal air cells. There was trace mucosal thickening of the maxillary sinuses and narrowing of the maxillary infundibula due to adjacent Haller cells. No fluid was noted in the maxillary sinuses, and the findings were not classified as sinusitis. An examination reported boggy, erythematous, and hypertrophic turbinates, but no conclusive documentation of visualized edema in the middle meatuses, ethmoids, or frontal infundibula. In this clinical setting, there is insufficient peer-reviewed evidence to support the use of balloon sinuplasty. Therefore, balloon sinuplasty is not likely to be more beneficial for treatment of the enrollees condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested balloon sinuplasty 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 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 otolaryngology with sub-specialty certification in sleep medicine and is actively practicing. Physician reviewers 2 and 3 are board certified in otolaryngology 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: An enrollee has requested authorization and coverage for Saxenda pen injector 3 mg/0.5 mL (18 mg/3 mL).Obesity is associated with increased risk of multiple comorbidities. Few medications are currently available for the treatment of obesity, and their effectiveness and benefits often fade when the drugs are discontinued. Saxenda (liraglutide) may be prescribed for chronic weight management as an adjunct to a reduced-calorie diet and increased physical activity. Nuffer and Trujillo noted, Data demonstrated that liraglutide can successfully achieve weight-loss benchmarks of 5% or more and 10% or more loss from baseline. In this case, the patient has struggled to lose weight despite a strict diet and regular exercise. Further, the patient is unable to take stimulants because she has tachycardia. Saxenda may assist this patient with losing weight and may have a positive effect in terms of her comorbidities, such as dyslipidemia. Thus, the Saxenda pen injector 3 mg/0.5 mL (18 mg/3 mL) is medically necessary for the treatment of the patients condition.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Nutropin AQ: growth hormone. The U.S. Food and Drug Administration (FDA) approves the use of Nutropin for the treatment of idiopathic short stature (ISS) in pediatric patients. Grimberg and colleagues note that ISS is defined by a height standard deviation score of 2.25. In this case, the patient is below the 1.2 percentile in growth with a poor interval growth velocity of five centimeters per year, which is low for a child starting puberty. The patients predicted final adult height is 150 cm, which is less than the mid-parental height of 63.75 inches and under 2.5 standard deviations of the mean for age and gender in growth. Given that the patient meets generally accepted diagnostic criteria for ISS, the requested medication is medically indicated. Therefore, Nutropin AQ: growth hormone 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has authorization and coverage for Stelara 90 mg every four (4) weeks. Findings:  The physician reviewer found that current medical literature supports dose escalation of Stelara to 90 mg every four weeks in this case. A large randomized controlled trial demonstrated safety and efficacy for induction and maintenance of remission in patients with moderate-severe Crohns disease that was resistant to anti-tumor necrosis factor (TNF) therapy. Another study showed a 73% response in patients with anti-TNF-resistant Crohns disease, and 80% of responders maintained remission for six months. The mechanism of Stelara (ustekinumab) is entirely different than that of anti-TNF medications, and the other medications. A study showed dosing at 90 mg every four weeks was used frequently to address inadequate disease control, and a large proportion of patients were able to maintain response with dose escalation to 90 mg every four weeks. Multiple studies have shown that a majority of patients in whom Stelara dosing every eight weeks failed to control symptoms responded to dosing every four weeks. In this case, the patient has symptoms and colonoscopy findings consistent with active Crohns disease on Stelara. The patient has failed multiple biologic and conventional alternatives, and had disease symptoms on Stelara every eight weeks. Use of Stelara every eight weeks or a change to another medication may result in worsening disease control, with complications such as fistula, stricture, bowel obstruction, flare, hospitalization, need for surgery, or other complications. For these reasons, Stelara 90 mg every four weeks is medically necessary for treatment of the patients Crohns disease.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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral breast reconstructive surgery. Findings:  The physician reviewer found that Cosmetic physicians often encounter patients who are dissatisfied with an objectively descent postoperative result. A mismatch between doctors and patients perception of the outcome leads to their frustration and occasionally aggressive behavior. The author further states, Unrealistic expectations, minimal deformities, history of multiple cosmetic interventions, decisional disturbances (profile of maximizer), looking for a secondary gain, familiar disagreement, body dysmorphic disorder, depression, anxiety, and personality disorders have been found to correlate with postoperative dissatisfaction. Baslaim and colleagues reported that in 26 breast reductions, All patients were happy about the reduced breast heaviness, but their satisfaction with the breast shape and scars was variable: 19/26 (73.1%) were highly satisfied, 3/26 (11.5%) were satisfied, 2/26 (7.7%) found the results acceptable but were not satisfied, and 2/26 (7.7%) were completely dissatisfied.In this case, the patient underwent a breast reduction and has undergone several subsequent procedures. She has no functional complaints of pain. Photographs show minor asymmetry and flattening of the inferior pole of the right breast. Given that the breasts appear within the wide range of normal for a female, and within the range of normal after breast reduction surgery, the requested services are not medically indicated. Therefore, bilateral breast reconstructive surgery is not medically necessary for the treatment of this patients condition.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 case, breasts are not abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease, and are within the wide range of appearance for normal female breasts. There records do not reflect functional complaints. Accordingly, the requested bilateral breast reconstructive surgery is not reconstructive in nature for treatment of this patient.Final Result: The reviewer determined that the requested service is not medically necessary for treatment of the patients medical condition and is not reconstructive in nature. 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.