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

Findings:  The physician reviewer found that An enrollee has requested reimbursement for DecisionDx-Melanoma genetic testing. The U.S. Food and Drug Administration (FDA) has not approved the DecisionDx-Melanoma gene expression profiling (GEP) test for the staging or treatment of patients with melanoma. In addition, there is a paucity of consensus or current medical literature to demonstrate the clinical utility, appropriate use, or improved outcomes with use of the DecisionDx-Melanoma test for patients with melanoma. The National Comprehensive Cancer Network (NCCN) does not recommend routine use of the DecisionDx-Melanoma assay to help direct treatment, thus the information yielded with this test would not change the patients outcome or treatment. Furthermore, the American Academy of Dermatology (AAD) guidelines have not reported benefits with use of the DecisionDx-Melanoma test in the evaluation and treatment of patients with melanoma. The standard of care for this patient included a wide local excision and then periodic follow-up skin examination. All told, the DecisionDx-Melanoma genetic testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings: Two of the three physician reviewers found the services at issue were 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Findings:  The physician reviewer found that The patient has requested reimbursement for inpatient hospital services. In this case, the patient was admitted for hospitalization appropriately for evaluation and management following an ischemic event. The patient  underwent a thorough neurological work-up including computed tomography (CT) and magnetic resonance imaging (MRI)  examining the brain and neurovasculature. Notes reported that the patient was cleared for discharge by neurology. Given that there is no evidence supporting any acute inpatient needs, and as the patient appeared hemodynamically stable and without neurological fluctuations, the services at issue were not medically necessary. Therefore, inpatient hospital services were not medically necessary for the 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient has requested authorization and coverage for fleur-de-lis abdominoplasty. According to the American Society of Plastic Surgeons (ASPS), when surgery to remove extensive skin redundancy and fat folds is performed solely to enhance a patients appearance in the absence of any signs or symptoms of functional abnormalities, the procedure should be considered cosmetic in nature. According to the ASPS, a cosmetic abdominoplasty is sometimes performed at the time of a functional panniculectomy or delayed pending completion of weight reduction. Abdominoplasty, typically performed for cosmetic purposes, involves the removal of excess skin and fat from the pubis to the umbilicus or above, and may include fascial plication of the rectus muscle diastasis and a neoumbilicoplasty. In this patients case, the records do not document functional abnormalities that would be addressed by the requested fleur-de-lis abdominoplasty. Therefore, the requested fleur-de-lis abdominoplasty is not medically necessary for the 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 case, the records document that this patients panniculus hangs below the level of the pubis. The patients hanging panniculus causes recurrent intertrigo in the infrapannicular area despite appropriate medical treatment including proper hygiene and the use of Nystatin cream. The patient has a documented functional problem with the rash that has been demonstrated to be resistant to appropriate medical treatment. A hanging panniculus that causes such a functional problem is considered an abnormal structure of the body caused by a developmental abnormality. However, an abdominoplasty will not address the patients overhanging pannus or improve function. The patients appearance is normal and consistent with gain and loss of weight. Moreover, the requested surgery will not make a more than minimal improvement in the patients appearance. Therefore, the requested fleur-de-lis abdominoplasty is not reconstructive in nature for patient.Final Result: The reviewer determined that the requested services are not medically necessary and not reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Findings:  The physician reviewer found that The patient has requested authorization and coverage for positron emission tomography/computed tomography (PET/CT) scan. The records provided for review document that this patient has a history of bilateral breast cancer status post bilateral mastectomy. The patients provider has recommended evaluation with PET/CT for staging purposes. However, there is a lack of support for PET/CT for assessment of this patient based on the available documentation. The National Comprehensive Cancer Network (NCCN) guidelines do not recommend PET/CT scan as an initial staging diagnostic tool for the evaluation of patients with non-metastatic breast cancer work-up. The NCCN states that, Routine systemic staging is not indicated for non-metastatic (M0) cancer in the absence of signs or symptoms. The NCCN supports use of PET/CT with diagnostic CT when standard staging studies are equivocal or suspicious, or to identify unsuspected regional nodal disease and/or distant metastases when used in addition to standard staging studies. Although this patient has an unexpected cancer on the left breast with microinvasion of the lymph node, the provider did not recommend a standard initial staging tool such as a staging CT scan chest, abdomen, and pelvis with contrast to evaluate for any equivocal or suspicious findings. The patients records do not establish a current indication for evaluation with PET/CT. All told, the requested PET/CT scan is not medically necessary for this patient. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation 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 Adderall XR 15 mg daily. This patients records support a diagnosis of ADHD, predominantly inattentive type, which was diagnosed in childhood. The provider reported that the patient has been treated with Adderall XR, Concerta, and Focalin XR. Given the patients longstanding diagnosis of ADHD and reported benefit in her ADHD symptoms from the previous medication regimens, the patient is an ideal candidate for continued treatment for her ADHD. The patients provider has recommended treatment with Adderall XR 15 mg, which has been beneficial for the patient in the past. Per Geffen and Forster, Stimulants are first-line pharmacologic agents for adult ADHD with a long history and moderate to large effect. The authors commented further that, Long-acting formulations allow once-daily simple treatment regimens so in the real world they are more effective than short-acting preparations and less prone to abuse/diversion. This patients provider noted that treatment with Adderall IR is not recommended for this patient due to the potential risk for tolerance and dependence. The provider charted that the patient has a long history of positive response to Adderall XR 15 mg daily. Given these findings, the requested Adderall XR 15 mg daily is medically necessary for treatment of this patient. The requested medication is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, Adderall XR 15 mg daily is clinically appropriate in terms of type, frequency, extent, site, and duration. Adderall XR 15 mg daily is 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.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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Rituxan (rituximab). chronic inflammatory demyelinating polyneuropathy (CIDP) is an acquired, immune-mediated neuropathy affecting peripheral nerves and nerve roots.  Medical literatures note that first-line therapies include intravenous immunoglobulin (IVIg), corticosteroids, and plasma exchange. In this case, while the records note that the patient has inadequate response to IVIg, the records do not document adverse effects or poor clinical response to plasma exchange and steroids. CIDP is not an approved indication for the use of Rituxan by the U.S. Food and Drug Administration (FDA) and there is a lack of evidence in current medical literature supporting its use in this clinical setting. Given that the records do not document that this patient has tried and failed first-line therapies, the requested medication is not medically indicated. Therefore, Rituxan (rituximab) 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 neurology with sub-specialty certification in vascular 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Orencia (1,000 mg intravenous (IV) loading dose following in one week by self-administered 125 mg weekly subcutaneous maintenance doses). The available records document that this patient developed psoriasis as a result of treatment with tumor necrosis factor inhibitor (TNFi) therapy with Humira. The patients provider indicated that alternate TNFi therapy such as Enbrel or infliximab should be avoided. In a retrospective study of patients who developed TNFi-induced psoriasis over a 10-year period, the authors reported that switching to an alternate form of TNFi therapy resulted in persistent or recurrent psoriasis in approximately 50% of patients (Mazloom, et al.). These findings are consistent with additional studies in the peer-reviewed medical literature. In addition, the U.S. Food and Drug Administration (FDA) indications state that treatment with Janus kinase (JAK) inhibitors including Rinvoq and Xeljanz carry the potential for major adverse cardiovascular events. This patient is noted to have several cardiovascular risk factors including obesity, hyperlipidemia, hyperglycemia as well as a family history of stroke in her mother and father. Moreover, the patient has a history of reported liver disease with transaminitis on laboratory testing. In light of the patients liver disease, her existing cardiovascular risk factors and the risk of major adverse cardiovascular events with Rinvoq and Xeljanz, avoidance of these medications is medically appropriate. According to the American College of Rheumatology (ACR) guidelines, Orencia is an acceptable FDA approved biologic disease modifying anti-rheumatic drug (DMARD) indicated for the treatment of patients with rheumatoid arthritis. Treatment with Orencia is appropriate for this patient given her preexisting cardiovascular risk factors, liver disease, and TNFi-induced psoriasis. Therefore, the requested Orencia (1,000 mg IV loading dose following in one week by self-administered 125 mg weekly subcutaneous maintenance doses) 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 internal medicine with subspecialty certification 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for tension-based orthotic brace with accessories. Pectus carinatum defect is chest wall deformity for which nonoperative bracing has been utilized with good patient health outcomes. In the American Pediatric Surgical Association (APSA) guidelines, equivalent outcomes are noted for nonoperative therapy utilizing orthotic bracing and dynamic compression when compared to operative therapy in well selected pediatric patients (Shaul, et al.). One review on the available evidence-based treatment modalities available to patients with pectus carinatum reported that bracing has become the preferred strategy to manage younger patients with pliable chest walls (Buziashvili, et al.). Based upon the information provided, current guidelines, and peer-reviewed medical literature, the requested tension-based orthotic brace and accessories are appropriate for management of this patients pectus carinatum defect. The recommended custom tension brace and protective body shirt can potentially eliminate the need for surgical intervention to correct the patients pectus carinatum defect. All told, the requested tension-based orthotic brace with accessories is medically necessary for treatment of this patient. 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 pediatrics with subspecialty certification in pediatric critical care 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 Norco. At issue is whether the requested Norco is medically necessary for treatment of this patient. The Centers for Disease Control and Prevention (CDC) guidelines state that when opioid therapy is used, a patients regimen should include nonpharmacologic therapy and nonopioid pharmacologic interventions. Additionally, the CDC noted that, Clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety. The Federation of State Medical Boards (FSMB) guidelines noted that, continuation, modification or termination of opioid therapy for pain is contingent on the clinicians evaluation of (1) evidence of the patients progress toward treatment objectives and (2) the absence of substantial risks or adverse events, such as signs of substance use disorder and/or diversion. The FSMB opined that dosage should be maintained as low as possible and continue[d] only if clear and objective outcomes are being met. In this case, the patient has chronic abdominal pain secondary to alcoholic cirrhosis. The records document that this patients provider has recommended cessation of alcohol consumption. The patient was referred to physical therapy, but the records indicate that she missed her appointments. The patient was also referred to pain management, but there are no reports from pain management in the available information. Furthermore, the patients providers have not recommended opioid therapy with Norco due to the unfavorable risk-to-benefit ratio. The patients providers have recommended non-pharmacological treatment modalities, which is consistent with current recommendations from the CDC and FSMB guidelines. Based on these findings, the requested Norco 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Dupixent 200 mg/1.14 mL syringe, 2 syringes/28 days. The U.S. Food and Drug Administration (FDA) approves the use of Dupixent, an interleukin-4 receptor alpha antagonist, for the treatment of patients aged six years and older with moderate-to-severe atopic dermatitis whose disease is not adequately controlled with topical prescription therapies or when those therapies are not advisable. Boguniewicz and colleagues note that moderate-to-severe atopic dermatitis is defined as involving over 10% of BSA and/or involvement of highly visible areas or those that are important for function such as the hands, neck, face, and genitals, and significantly impaired quality of life. Seigels and colleagues note that the data supporting the safety and efficacy of the use of dupilumab (brand name Dupixent) in moderate-to-severe atopic dermatitis is substantial. Systemic cyclosporine is contraindicated in those with hypertension and kidney impairment, is immunosuppressive and associated with increased infection risk, and is not recommended for younger children. The use of methotrexate, an immunosuppressive, has been associated with increased hospitalization if a patient is infected with COVID-19, and immunosuppressives such as methotrexate, mycophenolate, azathioprine, and cyclosporine may reduce the response to vaccination. In this case, the patient has severe, wide-spread atopic dermatitis. The patient has tried and failed topical steroids and Protopic. In this clinical setting, the use of the requested medication is medically indicated. Therefore, Dupixent 200 mg/1.14 mL syringe, 2 syringes/28 days, 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Intracept procedure. This patients records document a history of low back pain that has been treated with facet injections, non-steroidal anti-inflammatory drugs (NSAIDs), radiofrequency ablations, and epidural steroid injections without adequate pain relief. The patient has requested treatment with the Intracept procedure. The current peer-reviewed medical literature provides substantial data demonstrating the long-term efficacy and safety of the Intracept procedure in the treatment of patients with chronic low back pain as compared to ongoing conservative care. Fischgrund and colleagues noted that patients who underwent treatment with radiofrequency ablation of the basivertebral nerve for chronic low back pain exhibited significantly greater improvement in Oswestry Disability Index (ODI) at three months and a higher responder rate than sham treated controls. Truumees and colleagues found that minimally invasive radiofrequency ablation of the basivertebral nerve demonstrated a significant improvement in pain and function in patients with chronic vertebrogenic-related low back pain. Given this support, the requested Intracept procedure is 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 services are 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 reviewer 1 is board certified in orthopedic surgery and is actively practicing. Physician reviewer 2 is board certified in orthopedic surgery and is actively practicing. Physician reviewer 3 is board certified in orthopedic 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.