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 an Orthovisc injection series in the right knee. Findings:  The physician reviewer found that the the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and 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 a history of osteoarthritis of the right knee and lasting benefit from prior injections. Furthermore, the options are limited. The patient has chronic renal disease and is unable to take NSAIDs, with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, an Orthovisc injection series in the right knee 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.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: The provider noted that the patient initially underwent treatment with a complete response but has now relapsed with central nervous system (CNS) involvement. The patient was being treated with methotrexate and rituximab. The treatment plan included methotrexate in combination with temozolomide and rituximab. The patient underwent a left orchiectomy and treatment with cyclophosphamide and rituximab. The patient subsequently underwent right orchiectomy and treatment with intrathecal methotrexate. The patient has requested authorization and coverage for Temodar (temozolomide). The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether Temodar (temozolomide) is medically necessary for the treatment of the patients medical condition. Researchers reported, The rituximab, temozolomide and methotrexate regimen is an effective therapy for patients with primary central nervous system lymphoma (PCNSL) without the toxicities typically associated with consolidation therapy. Researchers noted, This study investigated the treatment of primary CNS lymphoma with methotrexate, temozolomide (TMZ), and rituximab, followed by hyperfractionated whole-brain radiotherapy (hWBRT) and subsequent TMZ. Researchers reported, This regimen is safe, with the best two-year overall survival and progression-free survival achieved in any Radiation Therapy Oncology Group primary CNS lymphoma trial. Researchers reported, In this large international cohort of patients treated with first-line immunochemotherapy, outcomes following secondary central nervous system (SCNS) involvement remain poor. However, a moderate proportion of patients with isolated SCNS who received intensive therapies achieved durable remissions. In this case, the patients treatment options are limited. The combination of temozolomide with methotrexate and rituximab has been shown to effective and relatively safe. The medical evidence supports the requested medication in this clinical setting. Therefore, Temodar (temozolomide) 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 medical oncology 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 ustekinumab (Stelara) 90 mg/mL injections. Stelara is U.S. Food and Drug Administration (FDA) approved for Crohns disease. A large randomized controlled trial demonstrated safety and efficacy for induction and maintenance of remission in patients with moderate-to-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 one year. The mechanism of Stelara is different from immunosuppressants and anti-TNF medications, which this patient has failed. A recent study demonstrated that a significant majority of patients who have failed an anti-TNF medication achieve and maintain response with Stelara. In this case, Stelara can control the patients disease and prevent further complications. For these reasons, the requested ustekinumab (Stelara) 90 mg/mL injections are medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in 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 reimbursement for Substance abuse partial hospitalization program (PHP) level of care services. Findings:  The physician reviewer found that  The patient has requested reimbursement for Substance abuse partial hospitalization program (PHP) level of care services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient did not meet Level 2.5 criteria for PHP services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. For dimension 1, the patient had no signs or symptoms of withdrawal and his withdrawal needs could be safely met in a Level 2.5 setting. For dimension 2, the patient had a low testosterone level. The patients biomedical problems were stable and did not interfere with treatment. For dimension 3, the records do not document any psychiatric symptoms. For dimension 4, the patient admitted himself voluntarily at the encouragement of his wife and friends. He was motivated to complete the program. He did not appear to have problems with impulse control or to have unrealistic expectations that his alcohol problem will resolve quickly or with little effort. The records do not document failures at a prior level of care. For dimension 5, the patient reportedly relapsed after an 18-year history of sobriety. He was stepped down from a higher level of care before being admitted to the PHP. The patient did not lack awareness of relapse triggers, demonstrate difficulty in coping or postponing immediate gratification, or to be ambivalent towards treatment. For dimension 6, the patient lives with his wife and he enjoys his job. His wife was supportive of his treatment goals. There is a lack of documentation to suggest that a return to his living environment would make his recovery unlikely. Given these findings, the patient did not meet the six ASAM dimensions for PHP level of care services. Accordingly, the substance abuse PHP level of care services 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 upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry with expertise in addiction 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 lidocaine 5% patch, 30-day supply. This patient was diagnosed with lung adenocarcinoma. He underwent a thoracotomy and subsequently developed chronic post-surgical pain (CPSP) affecting the right upper chest wall with associated numbness. Attempts to manage his pain have included Norco and Gabapentin with poor efficacy. The provider has recommended a lidocaine patch to apply to the affected area. A review study by Humble and colleagues evaluated the benefits of lidocaine patches for the prevention of CPSP after thoracic surgery. The authors found that, 5% lidocaine patches and ketamine do not prevent CPSP. Another review conducted by Moisset and colleagues evaluated pharmacological and non-pharmacological treatments for neuropathic pain. The authors focused on three studies evaluating the safety and efficacy of lidocaine patches for post-surgical and neuropathic pain. The authors found that the available evidence on the use of topical lidocaine in peripheral neuropathic pain is weak. In addition, the U.S. Food and Drug Administration (FDA) has only approved the lidocaine patch for use in the treatment of patients with post-herpetic neuralgia. Overall, there is a lack of evidence in the peer-reviewed medical literature and current FDA indications to support an indication for lidocaine patches in the treatment of CPSP. This patient does not have a diagnosis of post-herpetic neuralgia. Moreover, the records do not demonstrate that the patient has failed standard therapies for the treatment of CPSP. Therefore, the requested lidocaine 5% patch, 30-day supply is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has enrollee has requested authorization and coverage for a hypoglossal nerve neurostimulator. The records provided for review document that the patient has obstructive sleep apnea (OSA). A patient case summary reported that the patient had a body mass index (BMI) of 21.87 and his apnea/hypopnea index (AHI) was 18.9. The summary noted that a drug-induced sleep endoscopy (DISE) showed anterior posterior collapse. In a letter, the provider noted that the sleep endoscopy confirmed that the patient did not have complete concentric collapse of the upper airway. The patient was unable to tolerate a CPAP or dental device. The U.S. Food and Drug Administration (FDA) has approved the Inspire device for the treatment of OSA. Given the patients intolerance to CPAP therapy, anterior posterior collapse, no central apnea, and BMI and AHI within FDA criteria, the patient is a candidate for the Inspire device. Therefore, the requested hypoglossal nerve neurostimulator is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings: Three of the three physician reviewers found the requested hypoglossal nerve neurostimulator is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in 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: The patient has requested authorization and coverage for Xifaxan tablets. Findings: A study concluded that rifaximin seemed effective and safe for the treatment of SIBO. Another study found that rifaximin, a nonsytemic antibiotic, was effective against SIBO and well tolerated. Other research noted the rifaximin was the most commonly prescribed antibiotic regimen for SIBO therapy and that treatment with rifaximin may be highly effective in providing symptom relief from the effects of SIBO. In this case, the patient has tested positive for SIBO and has persistent associated symptoms. Therefore, Xifaxan tablets are 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for the medication Dupixent. Dupixent is a medication that is FDA approved for treatment of moderate and severe atopic dermatitis in patients age six and over. Dupixent (dupilumab) may be a good alternative for those with moderate to severe atopic dermatitis with an acceptable safety profile, which was also reiterated in a phase 3 randomized controlled trial. In this case, the patient has been dealing with atopic dermatitis since early childhood. The patient is noted to have flares, with the most recent and severe flare being one that the patient sought care for this year. The patient has been treated with topical steroids, topical antibiotics and anti-histamines. Other systemic therapies such as phototherapy and other immunosuppressants have been recommended. The schedule for phototherapy, however, is not feasible for a school-aged child, and immunosuppressants have sides effects to be considered. Under these circumstances, the favorable safety profile of Dupixent must be taken into consideration. Accordingly, the requested medication Dupixent is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary to treat the patient's 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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for Suction-assisted protein lipectomy (SAPL). Based on the available documentation, the SAPL was medically necessary for treatment of this patient. The provider noted that the patients lymphedema was causing functional issues with an impact on his ability to work and perform his activities of daily living. He has attempted conservative therapy with manual lymphatic drainage and compression therapy without substantial improvement. Current peer-reviewed medical literature supports an indication for SAPL in this clinical setting. Researchers noted that, lipoaspiration for treatment of lower limb lymphedema, followed by controlled compressive therapy (which must be continued to maintain the reduction volume reached by lipoaspiration), can potentially improve late stages 2 and 3 of chronic lymphedema when conservative therapy is ineffective. This procedure has been demonstrated to improve functionality and quality of life and decrease the rate of infection in lower limb lymphedema. Further, medical literature reported that, Several studies have confirmed the efficacy and long-term stability of large-volume suction assisted lipectomy debulking for reducing limb volume to that similar to the unaffected side for both the upper and lower extremities In addition, the incidence of cellulitis is reduced dramatically postoperatively. Given these findings, the SAPL was medically necessary for treatment of the patients medical 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; (2) to create a normal appearance, to the extent possible. The records provided for review demonstrate that this patient has an enlarged leg secondary to lymphedema. This condition is related to prior infection and a surgical procedure that remove the patients inguinal lymph nodes. The surgery was performed to improve function and activities of daily living and would improve the patients appearance since the legs will be more symmetrical. Therefore, the SAPL was also reconstructive in nature for treatment of the patients medical condition.Final Result: The reviewer determined that the services at issue were medically necessary and reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. 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 reimbursement for Monovisc injection. Findings: Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines 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 had tried and failed other conservative treatments, such as corticosteroid injections. They have status post left knee arthroscopy. Given the patients limited options and based on the current medical literature, the service at issue was medically indicated. Therefore, the Monovisc injection in the left knee was medically necessary for the treatment of this patient. Final Result: The reviewer determined that the service at issue was 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 enrollees parent has requested reimbursement for nitric oxide expired gas determination (CPT 95012). Findings:  The physician reviewer found that the records provided for review do not include documentation poorly controlled asthma or multiple emergency department visits or hospitalizations which are suggestive of poor control. Moreover, there is a paucity of medical literature or clinical guidelines to support a role for nitric oxide expired gas analysis to determine airway inflammation in this patient. van Mastrigt and colleagues found that that analysis of volatile organic compounds in exhaled breath is still a research tool and not validated for clinical use. Hence, the nitric oxide expired gas determination (CPT 95012) was 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 nitric oxide expired gas determination (CPT 95012) was 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 services at issue were 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 certifications in pulmonary disease and critical care medicine and is actively practicing. Physician reviewer 2 is board certified in pediatrics with subspecialty certifications in medical toxicology and pediatric pulmonology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certification in pulmonary disease 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.