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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Xeljanz extended release. Findings:  The physician reviewer found that current peer-reviewed medical literature, Xeljanz has not been shown to be safe and effective for the treatment of Crohns disease based on well-designed randomized controlled trials. There are studies demonstrating the safety and efficacy of Xeljanz in patients with ulcerative colitis. However, the data has not reported superior patient outcomes with Xeljanz as compared to standard available therapies in the treatment of patients with Crohns disease. Sandborn and colleagues found that Xeljanz was more effective as induction and maintenance therapy than placebo. However, the authors also noted that Xeljanz was associated with increased lipid levels. Given these data, additional studies are needed to assess the clinical role of Xeljanz, if any, in the treatment of Crohns disease. All told, the requested Xeljanz extended release is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested Xeljanz extended release 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 treatment 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 gastroenterology 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hypoglossal nerve stimulation with Inspire upper airway stimulation system. The available records document that this patient has obstructive sleep apnea (OSA) that has failed to improve despite treatment with continuous positive airway pressure (CPAP) therapy. The patients provider noted that the patient is not an optimal candidate for oral appliance therapy due to the severity of OSA. There is adequate evidence in the peer-reviewed literature to support the safety, efficacy, and long-term improvement of hypoglossal nerve stimulation with the Inspire procedure in patients with moderate to severe OSA. A meta-analysis demonstrated clinically significant decreases in observed mean apnea/hypopnea index (AHI) and Epworth Sleepiness Scale (ESS) scores, as well as improvements in quality of life scales. The American Academy of Otolaryngology Head and Neck Surgery (AAOHNS) considers upper airway stimulation with the Inspire device via the hypoglossal nerve to be a safe and effective second-line treatment of moderate to severe OSA in patients who are intolerant or unable to achieve benefit with CPAP. For this patient with a body mass index (BMI) of 27.44 kg/m2 and an AHI of 22 events per hour, the Inspire procedure is likely to be more beneficial than CPAP or an oral appliance. Therefore, the requested hypoglossal nerve stimulation with Inspire upper airway stimulation system 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 hypoglossal nerve stimulation with Inspire upper airway stimulation system 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for office visits (99204 x 4) and electrolysis services (17380 x 96). Findings:  The physician reviewer found that Medically necessary treatment of a mental health or substance use disorder means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of that illness, injury, condition, or its symptoms, in a manner that is all of the following: (i) in accordance with the generally accepted standards of mental health and substance use disorder care; (ii) clinically appropriate in terms of type, frequency, extent, site, and duration; (iii) 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.Coleman and colleagues authored standards of care that lists hair removal through electrolysis, laser treatment, or waxing as a standard treatment to alleviate gender dysphoria. Additionally, the World Professional Association for Transgender Health (WPATH) supports facial hair removal and gender affirming counseling or psychotherapeutic treatment for the treatment of patients with gender dysphoria. In this case, the patient has been diagnosed with gender dysphoria. Moreover, the patient desires to have hair removed in areas visible to others in order to conform to her chosen gender role. There is sufficient support for the requested services in this clinical setting. Therefore, office visits (99204 x 4) and electrolysis services (17380 x 96) are medically necessary to treat the patients medical condition as defined in Health and Safety Code section 1374(a)(3)(A). Specifically, the requested services are in accordance with the generally accepted standards of mental health and substance use disorder care. The requested services are clinically appropriate in terms of type, frequency, extent, site, and duration. Additionally, the requested services are 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 services are medically necessary for treatment of the patients medical condition as defined in Health and Safety Code section 1374(a)(3)(A). Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry with expertise in transgender 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 reimbursement for intermediate outdoor behavioral healthcare services from Redcliff Ascent Wilderness Therapy. DeMille and colleagues report regarding the effectiveness of outdoor behavioral healthcare, Findings showed that youth participants one-year post participation in outdoor behavioral healthcare treatment were functioning significantly better than youth who remained in their communities. However, this study did not compare outdoor behavioral health treatment with standard residential treatment in a licensed facility, which would be considered a standard therapy of equivalent intensity. In this case, the patient was admitted to an outpatient behavioral healthcare program. The patients parent noted that the patient had seen a psychologist and received medication management. The submitted documentation did not show evidence of other treatment attempts at other levels of care such as intensive outpatient program (IOP), partial hospitalization program (PHP), or residential treatment center (RTC). A family call log reported that the family was encouraged to finalize plans with a residential treatment center to prepare for the patients discharge, suggesting that the care offered at the OBH was not effective enough to permit the enrollee to return home. Therefore, intermediate outdoor behavioral healthcare services from Redcliff Ascent Wilderness Therapy were not likely to have been more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the intermediate outdoor behavioral healthcare services from Redcliff Ascent Wilderness Therapy at issue was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were not likely to have been 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 reviewers 1, 2, and 3 are board certified in psychiatry 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 electric breast pump. The American College of Obstetricians and Gynecologists (ACOG) endorse and encourage breastfeeding. Per ACOG, in clinical circumstances where breastfeeding is challenging, pumping breast milk is an acceptable alternative. Breast pumping is most effectively performed with an electric breast pump. In this situation, the patient has overproduction of breast milk, which could lead to infection and difficulty for the infant latching. For these reasons, the requested electric breast pump is medically necessary for this patient. Final Result: The reviewer determined that the requested device 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 obstetrics and gynecology 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 reimbursement for a Guardant360 biopsy-free tumor sequencing test. The National Comprehensive Cancer Network (NCCN) guidelines for the treatment of breast cancer note that mutational testing for metastatic tumors may suggest some targeted therapies, and specifically mention liquid biopsies. Shimelis and colleagues report that patients with mutations identified by multigene hereditary cancer panel testing may benefit from specific targeted therapeutic strategies. PIK3CA is one such example. In most instances of visceral disease or lymph node involvement, testing may be performed on the excised tissue, however, in certain cases, such as bone metastases, the decalcification process makes the material unsuitable for gene sequencing. In this clinical setting, the results from molecular profiling would assist in making a rational decision on the next treatment regimen. Therefore, the Guardant360 biopsy-free tumor sequencing test was likely to have been more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the Guardant360 biopsy-free tumor sequencing test at issue was likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was likely to have been 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 and 2 are board certified in internal medicine with sub-specialty certifications in medical oncology and hematology and are actively practicing. Physician reviewer 3 is board certified in internal medicine with sub-specialty 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Humira.Findings: According to a study, the use of tumor necrosis factor (TNF) inhibitors in patients with psoriatic arthritis resulted in good responses and benefit from treatment. Moreover, disease-modifying antirheumatic drugs (DMARDs), such as methotrexate, Arava, and sulfasalazine, are strictly contraindicated in patients who have a history of current use of alcohol. In this case, the patient has been diagnosed with psoriatic arthritis based on their symptoms of joint pain, swelling in multiple fingers, and x-ray evidence of erosive disease in the hands. Considering that they have an aggressive disease with signs of multiple joints involved, the patient would benefit from Humira. The submitted documentation reflects that the patient has a history of alcohol dependence and hepatotoxicity. Since this patient has elevated anti smooth muscle antibodies that could be indicative of additional pathology of the liver, the use of DMARDs is contraindicated and not recommended. Therefore, the requested Humira 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for anterior optical coherence tomography (OCT) (CPT 92132) provided by UCLA Jules Stein Eye Institute. Hwang and colleagues note that spectral-domain (SD) optical coherence tomography (OCT) may be used to distinguish patients with asymmetric keratoconus (AKC). While anterior OCT imaging is not necessary for routine use before penetrating keratoplasty, deep anterior lamellar keratoplasty (DALK), Descemet membrane endothelial keratoplasty (DMEK), or Descemet stripping automated endothelial keratoplasty (DSAEK) surgery, in this clinical setting, anterior OCT to image the cornea to determine the fitness of one of the available surgical options for keratoconus would be useful. OCT imaging of the posterior cornea is superior to the other option for evaluating the corneal fitness for keratoplasty, slit-lamp examination and specular microscopy, for discovering breaks in the Decemet membrane, especially when there is corneal scarring or a poor direct view of the posterior cornea.  In this clinical setting, the anterior OCT (CPT 92132) provided by UCLA Jules Stein Eye Institute was likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the anterior optical coherence tomography (OCT) (CPT 92132) provided by UCLA Jules Stein Eye Institute at issue was likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was 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 ophthalmology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for night splint/ankle foot orthotic (AFO) (code L4397). The records provided for review document that this patient presents with bilateral foot pain. Foot pain and heel pain are common, especially in obese patients. Conservative nonsurgical treatment is recommended and has been demonstrated to be effective for most patients with foot and heel pain. Goff and Crawford noted that, Initially, patient-directed treatments consisting of rest, activity modification, ice, massage, oral analgesics, and stretching techniques can be tried for several weeks. If heel pain persists, then physician-prescribed treatments such as physical therapy modalities, foot orthotics, night splinting, and corticosteroid injections should be considered. In this case, initial treatment of foot pain should be patient-directed consisting of activity modification, ice, stretching techniques, analgesic medications such as acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs), and weight loss. The records provided for review do not document that the patient has failed treatment with first-line therapies to support an indication for the requested night splint/AFO. Therefore, the requested night splint/AFO (code L4397) is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested device 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 with subspecialty certification in sports 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for IVIg Gammagard liquid 10% (37 grams every 2 weeks). Hovaguimian and Gibbons note that management of small-fiber neuropathy depends on the underlying etiology with concurrent treatment of associated neuropathic pain. Finnerup and colleagues report that inadequate response to drug treatments constitutes a substantial unmet need in patients with neuropathic pain. Liu and colleagues report evidence suggesting that intravenous immunoglobulin (IVIg) is safe and effective as a first-line treatment for patients with small-fiber-targeting autoimmune diseases akin to Guillain-Barre and chronic inflammatory demyelinating polyneuropathy. The authors note in a study of 55 patients with small-fiber polyneuropathy that overall, 74% of patients rated themselves as improved and their neurologists labeled 77% as IVIg responders. The authors further noted that 16% of the participants entered remissions that were sustained after IVIg withdrawal. In a review of various studies regarding immunotherapy for distal small-fiber polyneuropathy, Oaklander reports, These reports provide a rationale for treating carefully selected patients with immunomodulatory therapies. Candidates should have symptoms consistent with small-fiber polyneuropathy, objective confirmation of diagnosis, exclusion of other causes, failure to improve with symptom management, and, ideally, serologic markers of immunity/inflammation. In this case, the patient has small-fiber polyneuropathy. A providers letter reported laboratory evidence of autoimmunity. Current medical literature supports the finding that  patients with autoimmune small fiber neuropathy may improve clinically with IVIg. Therefore, IVIg Gammagard Liquid 10% (37 grams every 2 weeks) is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested IVIg Gammagard liquid 10% (37 grams every 2 weeks) 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 medication 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 and 2 are board certified in neurology and are actively practicing. Physician reviewer 3 is board certified in neurology with sub-specialty certification in vascular neurology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xiaflex injections (collagenase from clostridium histolyticum). In a systematic review of injection therapies for patients with Peyronie's disease, Russo and colleagues reported that there was evidence for improvements in penile curvature with clostridium histolyticum (brand name Xiaflex). In this case, the patient has a diagnosis of Peyronies disease. Given that surgical treatment would be reserved for cases in which medical management and Xiaflex therapy have failed, the requested services are medically indicated. Therefore, Xiaflex injections (collagenase from clostridium histolyticum) are 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 urology 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.