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 right cubital tunnel decompression surgery (CPT 64718, 15718, and 64727). This patient presents with complaints of persistent burning right elbow pain with constant numbness and tingling of the right small finger. Clinical examination findings have documented positive Tinels at the cubital tunnel, positive elbow flexion, and subluxation and snapping of the ulnar nerve with neuropathy during flexion. She has failed to improve despite nine months of activity modification, medications, right carpometacarpal (CMC) joint corticosteroid injection, and hand bracing. The patient has signs, symptoms, and clinical findings of cubital tunnel syndrome correlated with an electromyography/nerve conduction velocity (EMG/NCV) study. Current evidence-based medical literature supports proceeding with surgical intervention in this clinical setting. Studies noted that in cases of mild or moderate cubital tunnel syndrome, it is reasonable to attempt activity modification or splinting, as both appear to be equally effective. Researchers reported that conservative treatment might be effective in the early stages of cubital tunnel syndrome. The authors recommend surgery for patients who fail to improve with non-operative treatment, or those with more advanced clinical findings, such as motor weakness, muscle atrophy, or fixed sensory changes. Surgical intervention for primary cubital tunnel syndrome is cubital tunnel decompression surgery. For these reasons, the requested right cubital tunnel decompression surgery (CPT codes 64718, 15718 and 64727) 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Saxenda. Garvey and colleagues noted that, Obesity is a complex, adiposity-based chronic disease, where management targets both weight-related complications and adiposity to improve overall health and quality of life. The authors noted that the addition of pharmacotherapy produces greater weight loss and weight loss maintenance compared with lifestyle therapy alone. The U.S. Food and Drug Administration (FDA) has approved Saxenda for the treatment of obesity. Authors noted, Liraglutide treatment was associated with reductions in cardiometabolic risk factors, including waist circumference, blood pressure, and inflammatory markers. Modest improvements in fasting lipid levels were also observed, although the clinical relevance of these improvements is uncertain. Furthermore, patients in the liraglutide group had greater reductions in fasting and postprandial glycemic variables and more improvement with respect to beta-cell function and insulin sensitivity than did the placebo group. The combination of weight loss and improved glycemic control probably contributed to the observed reductions in the prevalence of prediabetes and the delayed onset of type 2 diabetes. In this patients case, she was successfully treated with Saxenda in the past. The medical evidence supports the requested medication in this clinical setting. Therefore, Saxenda is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism. 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 requested authorization and coverage for Cosentyx Sensoready (300 mg) Subcutaneous Auto Injector 150 mg/ml (starter and maintenance doses).In this case, the patient suffers from chronic, widespread plaque psoriasis and has failed to respond to treatment with class 1 topical corticosteroids and UV phototherapy. The requested medication, Cosentyx, is a generally accepted medical pharmacologic treatment of chronic plaque type psoriasis. The alternative medication methotrexate would not be a good choice for a patient who drinks alcohol regularly, and cyclosporine, another alternative, is a temporary treatment for psoriasis that is not to be used chronically, and this is a chronic disease. Under these circumstances, the requested medication, Cosentyx Sensoready (300 mg) Subcutaneous Auto Injector 150 mg/ml (starter and maintenance doses), is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary to treat 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for cardiac computed tomography angiogram (CCTA). This patient has multiple risk factors for cardiovascular disease. Her medications include antihypertensive and lipid lowering therapy. The patient underwent prior evaluation with a stress test, which was negative. The patient has symptoms of dyspnea on exertion and she is being treated for pulmonary disease as well. There is a lack of data supporting the use of CCTA in assessing the severity of coronary artery disease in a higher risk, symptomatic patient as a stand-alone test since it only detects calcified plaque. The American College of Cardiology (ACC) and American Heart Association (AHA) recommend CCTA for risk stratification of long-term cardiac risk in asymptomatic patients considered for risk reduction therapies like statins medication, lifestyle modifications and intensive diabetes management. In this instance, the patient is on a statin medication for her hyperlipidemia, amlodipine for blood pressure control, and metformin for diabetes to manage her cardiovascular risk factors. Thus, the requested CCTA 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 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 reviewers 1, 2, and 3 are board certified in internal medicine with subspecialty certification in cardiovascular disease and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for inpatient hospital services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient met Level 4 criteria for inpatient hospital services for a portion of the admission. According to the ASAM guidelines, the patient continued in withdrawal management at the appropriate level until his withdrawal signs and symptoms were sufficiently resolved such that he was stable for transfer to less intensive level of care. The first day of the Health Plans denial, the patient still required Level 4 monitoring for withdrawal management. He was on his third day of phenobarbital taper and still required lorazepam as needed. He was also still on intravenous fluids on this date. His pulse ranged from 93-109.  The patient reported that he was unable to walk without a walker due to phenobarbital and was provided with an assistive device. Thus, the first day of inpatient hospital services were medically necessary for this patient. However, by the next day, the patient was no longer in uncontrolled alcohol withdrawal and he had stable vital signs without reports of confusion or altered mental status. The patient was treated for severe withdrawal with improvement. He was having some difficulty coping with withdrawal discomfort. He was on oral medications and was being tapered off phenobarbital. The patient no longer required lorazepam to control his withdrawal. The patients lab abnormalities were consistent with alcohol use disorder that including mild hyponatremia and thrombocytopenia. The records do not document the presence of severe medical problems that required 24-hour medical and nursing care. The patient was found to be thrombocytopenic, mildly hyponatremic, and had elevated aspartate aminotransferase (AST). He reported that his ambulation was problematic while on phenobarbital. There were no other medical co-morbidities. The patient had complaints of anxiety. He was not suicidal, homicidal, or psychotic. He did not have any reported behavioral problems. Per ASAM, a patient who meets criteria in dimensions 1, 2, or 3 is appropriately placed in a Level 4 program. As this patient did not meet the criteria in dimensions 1, 2, or 3, the inpatient services from were not medically necessary per the ASAM guidelines. Given these findings, a portion of the inpatient hospital services were medically necessary for this patient. Final Result: The reviewer determined that a portion of the services at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry with subspecialty certification 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 Lidoderm patches. The U.S. Food and Drug Administration (FDA) has approved Lidoderm patches for the treatment of post-herpetic neuralgia. McColgan and colleagues report that there is a lack of evidence to support the use of Lidoderm patches for musculoskeletal pain. Santana and colleagues evaluated the medical evidence supporting the use of Lidoderm patches for chronic low back pain. The authors evaluated seven studies and concluded that they found no randomized controlled trials with substantial evidence to support the use of 5% lidocaine patch in chronic low back pain. In this case, the patient has a known diagnosis of traumatic brain injury and unspecified injuries to the lower back and neck. Her records do not show any history of post-herpetic neuralgia or any complaints related to this condition. The records show that the patient has been using the Lidoderm patches on her back for non-specific musculoskeletal back pain. Based on the FDA approval and current medical literature, the requested Lidoderm patches 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. 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: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for psychiatric services. Per Health and Safety Code Section 1317.1 (a)(2)(A): Emergency services and care also means an additional screening, examination, and evaluation by a physician, or other personnel to the extent permitted by applicable law and within the scope of their licensure and clinical privileges, to determine if a psychiatric emergency medical condition exists, and the care and treatment necessary to relieve or eliminate the psychiatric emergency medical condition, within the capability of the facility. In addition, Health and Safety Code Section 1317.1 (k)(1) Psychiatric emergency medical condition means a mental disorder that manifests itself by acute symptoms of sufficient severity that it renders the patient as being either of the following: (A) an immediate danger to himself or herself or to others; (B) immediately unable to provide for, or utilize, food, shelter, or clothing, due to the mental disorder. Based on the documentation provided for review, this patient had a mental disorder that manifested itself by acute symptoms of sufficient severity that it rendered him an immediate danger to himself and others during the period under review. The patient was at serious risk of harm due to impulsivity as demonstrated by his running away and going into abandoned buildings and random cars. In addition, he demonstrated serious functional impairment given his inability to perform in a specialized school setting due to disruptive behavior, which represents an impediment to care for self. Moreover, the patient has severe comorbidities with intellectual impairments that complicate his autism spectrum symptoms and attention-deficit/hyperactivity disorder (ADHD). Given this support, the emergency medical services provided were provided for the treatment of a psychiatric medical emergency. Final Result: The reviewer determined that the services at issue were emergency services as defined by California law.  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 with subspecialty certification in child and adolescent 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for speech therapy services. Ganz described that AAC devices provide a means of effective communication to individuals with autism spectrum disorder (ASD), many of whom are unable to use conventional speech effectively. The author describes that patients with autism stand to greatly benefit from AAC, particularly with current AAC technologies. Researchers reviewed the importance of early intervention for young patients with autism spectrum disorder, emphasizing that developmental and behavioral approaches often underlie the therapeutic strategies employed by speech and language pathologists. Although this patient has not met the goals set by his provider per the documentation provided, the patient has not plateaued in his progress. His ability to use his AAC device to communicate is improving, albeit slowly, and with less need for intensive prompting. All told, the medical literature supports the requested speech therapy services as 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 neurology with special qualification in child 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 been diagnosed with hypertension, dyslipidemia, and atherosclerotic heart disease. The records noted a history of percutaneous coronary intervention. The patient was noted to have experienced left-sided chest tightness associated with weakness and shortness of breath in 2006. The patient subsequently underwent cardiac stent placement. The patient was noted to have undergone a second cardiac stenting procedure. A myocardial perfusion study revealed normal left ventricular perfusion. The patients blood pressure was noted to be 146/90. The provider discontinued Azor and prescribed Edarbyclor and amlodipine. The patient denied chest pain, shortness of breath, and palpitations. The patients blood pressure was noted to be 140/100. Samples of Edarbyclor were provided to the patient. The patient has requested authorization and coverage for Edarbyclor 40 mg-12.5 mg tablet daily. 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 Edarbyclor 40 mg-12.5 mg tablet daily is medically necessary for the treatment of the patients medical condition. James and colleagues reported, There is strong evidence to support treating hypertensive persons aged 60 years or older to a blood pressure goal of less than 150/90 mm Hg and hypertensive persons 30 through 59 years of age to a diastolic goal of less than 90 mm Hg. Edarbyclor is indicated for the treatment of hypertension refractory to single drug therapy. In this case, the patient requires blood pressure control for longstanding hypertension in the setting of known ischemic heart disease. His blood pressure control was not at goal on Azor (amlodipine/olmesartan) therapy, and he had been switched to Edarbyclor (azilsartan/chlorthalidone) along with continued amlodipine for improved management. The patients blood pressure was noted to be 140/100. The medical evidence supports the requested medication in this clinical setting. Therefore, Edarbyclor 40 mg-12.5 mg tablet daily is medically necessary for the treatment of the patients medical 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 sub-specialty certification in cardiovascular disease 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 Keytruda 200 mg injection every three weeks. For the treatment of recurrent meningiomas, Keytruda is not FDA approved or supported by major drug compendia. However, the medical literature supports use of Keytruda in patients with increased programmed death-ligand 1 (PD-L1) expression, high mutational tumor burden, high frequency MSI, or mismatch repair (MMR) deficiency on sequencing that may increase the likelihood of responsiveness to immunotherapy. This patients tumor does not meet any of these criteria to indicate a likely response. Therefore, the requested Keytruda 200 mg injection every three weeks is not 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 Keytruda 200 mg injection every three weeks 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 medication is 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 board certified in internal medicine with subspecialty certification in medical oncology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. Physician reviewer 3 is board certified in board certified in internal medicine with subspecialty certification in medical oncology 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

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for an electric scooter. The enrollee has worsening pain in both feet. A progress note includes diagnoses of corns and callouses, and pain to bilateral feet and ankles. The patient was evaluated by her treating physician.  Medical records show the patient had bilateral bunions, with thick tender callusing of both feet.  However, there were no focal deficits.  The upper and lower extremity motor and sensory examinations were described as normal and intact; respectively. The patient was assessed for an electric scooter by a physical therapist.  The therapist reported the patient is fully ambulatory, without the use of a device, such as a cane, and was not restricted from driving a motor vehicle.  The patient has the necessary upper extremity function to self-propel an optimally-configured manual wheelchair to perform activities of daily living or instrumental activities of daily living during a typical day. The physical therapist's evaluation also reported the patients wheelchair inaccessible apartment does not provide adequate access between rooms, in and out of the home, maneuvering space, over surfaces, nor a secure storage space for the operation of the power operated vehicle.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.