Persius/hicric huggingface dataset:
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bilateral upper lid blepharoplasties.At issue is whether bilateral upper lid blepharoplasties are medically necessary for treatment of the patients medical condition. Does the condition constitute an abnormal structure of the body? If so, is the abnormal structure of the body caused by any of the following: congenital effects, developmental abnormalities, trauma, infection, tumors, or disease? If so, is the requested surgery performed to do either of the following: improve function or create a normal appearance to the extent possible? If so, does the surgery provide more than a minimal improvement in the appearance of the patient?According to medical literature, Upper blepharoplasty is accompanied by a great variety of beneficial functional outcomes including an increased visual field and improvement in headache- and vision-related quality of life. Moreover, medical literature indicate that upper blepharoplasty is functionally beneficial for patients with MRD less than or equal to 3 mm measured in primary gaze.This patient has dermatochalasis as evidenced by photographs. The physical examination demonstrates MRD less than 3 mm that is supported by the photographs. The visual fields, history and photographs are also compelling evidence of functional disability. Although there are varying degrees of dermatochalasis evident in the different photographs, there is enough deformity to explain the patients complaints and the results seen with visual field testing. Therefore, the requested bilateral upper lid blepharoplasties are medically necessary for treatment of the patients medical condition In this case, surgical treatment for the patient would be for the purpose of treating disease caused by involutional deformity of the eyelids that is causing symptomatic disability. This meets the typical criteria for appropriately treating a malformed body member. The blepharoplasty surgery is appropriate to treat this disease and relieve the patients symptoms of vision loss, and not merely for cosmetic benefit. Moreover, the requested blepharoplasties are to improve function. Therefore, the requested bilateral upper lid blepharoplasties are reconstructive in nature.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition and reconstructive in nature. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in ophthalmology 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

Findings:  The physician reviewer found that The patient has requested authorization and coverage for Zejula 100 mg capsules (two capsules daily for one year). The U.S. Food and Drug Administration (FDA) approves the use of Zejula (generic name niraparib), a poly (ADP-ribose) polymerase (PARP) inhibitor, for the maintenance treatment of recurrent epithelial ovarian, fallopian tube, or primary peritoneal cancer in adults who are in a complete or partial response to platinum-based chemotherapy. The National Comprehensive Cancer Network (NCCN) guidelines for ovarian cancer note that bevacizumab may be continued as maintenance therapy until disease progression or unacceptable toxicity. Bevacizumab should be discontinued before initiating maintenance therapy with a PARP inhibitor. Niraparib should be reserved for recurrence. Mirza and colleagues note that the use of niraparib and bevacizumab for the treatment of platinum-sensitive recurrent ovarian cancer warrants further evaluation and is the subject of continued phase III trials. Given the lack of current medical evidence supporting the use of the combination of nirparib with bevacizumab for maintenance therapy in this clinical setting, the requested medication is not medically indicated. Therefore, Zejula 100 mg capsules (two capsules daily for one year) are 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for lurbinectedin injection. The U.S. Food and Drug Administration (FDA) approves the use of lurbinectedin for the treatment of metastatic small-cell lung cancer in adults with disease progression on or after platinum-based chemotherapy. Given that the National Comprehensive Cancer Network (NCCN) guidelines for neuroendocrine and adrenal tumors do not endorse the use of lurbinectedin, and the lack of evidence in current medical literature supporting its use in this clinical setting, the requested medication is not medically indicated. Therefore, lurbinectedin injection 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 internal medicine with sub-specialty certification in medical oncology and hematology 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

Findings:  The physician reviewer found that The patient has requested authorization and coverage for Korlym 300 mg tablets. Chaudry and Singh explain that Cushing syndrome is caused by prolonged exposure to high circulating levels of cortisol and may lead to numerous signs and symptoms, including weight gain, fatigue, weakness, delayed wound healing, easy bruising, back pain, bone pain, loss of height, depression, mood swings, emotional reactivity, loss of libido, erectile dysfunction in males, irregular menstrual cycles in females, infertility, hyperhidrosis, and hirsutism. The authors further note that while hypercortisolism due to Cushing disease or adrenal tumor or ectopic tumor is best treated with surgical resection, alternative treatments are available for all forms of Cushing syndrome, including the oral medication mifepristone (brand name Korlym). Brown and colleagues note that mifepristone is a competitive glucocorticoid receptor antagonist and progesterone receptor antagonist that has been shown as a beneficial medical treatment option for patients with Cushing syndrome. Diaz-Castro and colleagues report that mifepristone may improve the glycemic control in patients with type 2 diabetes patients secondary to endogenous Cushing syndrome. Given that current medical literature supports the use of mifepristone in this clinical setting, the requested medication is medically indicated.  Therefore, Korlym 300 mg 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral Synvisc One injections. Findings:  The physician reviewer found that records document that this patient has a history of osteoarthritis of both knees for which viscosupplementation was successfully used in the past. Per the provider, the patient had previously received hyaluronic acid injections of both Synvisc One and Euflexxa with excellent results. Additional treatment has included physical therapy and other forms of conservative therapy without substantial improvement in symptoms. The provider has recommended repeat Synvisc One hyaluronic acid injections in both knees. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as routine treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patient has a history of prior viscosupplementation with excellent results. Furthermore, the  other conservative treatments including physical therapy have not been effective. For these reasons, the requested bilateral Synvisc One injections are 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Estradiol 6 mg daily and Prometrium 300 mg daily. This patients medical records include documentation from three providers who all performed thorough evaluations of the patient and recommended termination of oral Estradiol and Prometrium because of the risk of blood clots and cardiovascular events. The patients providers have suggested that the patient transition to transdermal estrogen. The guidelines from the University of California, San Francisco (UCSF) specifically reference older women, noting that there is a lack of evidence to support continuation or cessation of hormones for older transgender women. The guidelines further report that, Since the mean age of menopause in the U.S. is 49, it is reasonable in transgender women who have undergone gonadectomy to consider stopping hormone therapy around age 50. Furthermore, the guidelines from the Endocrine Society do not reference hormone therapy in older transgender females. Overall, the requested Estradiol and Prometrium are not in accordance with the generally accepted standards of mental health and substance use disorder care and are not clinically appropriate in terms of type, frequency, extent, site, and duration for treatment of this patient. Based on the current guidelines and medical literature, the requested Estradiol 6 mg daily and Prometrium 300 mg daily are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medications are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in diabetes, endocrinology, and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Humatrope. Findings: Somatotropin (brand name Humatrope) may be indicated for pediatric use for specific conditions, including pediatric growth hormone deficiency so long as epiphyses, or growth plates, remain open. In this case, a bone age study reported a chronological age of 17 years and two months and a bone age of 18 years, a stage consistent with closed epiphyses. The records documented a lack of growth. In this clinical setting, given that the submitted records show evidence consistent with closed epiphyses, the requested medication is not medically indicated. Therefore, Humatrope 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 pediatrics with sub-specialty certification in pediatric endocrinology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for lumbar/sacral facet joint block injection. Findings:  The physician reviewer found that the effectiveness of lumbar medial branch blocks and facet joint injections. The authors reported that, The higher responder rates in the treatment groups suggest a hypothesis that facet blocks might provide prognostic value before radiofrequency ablation. Another review published by Manchikanti and colleagues stated that, the evidence for lumbar facet joint nerve blocks using local anesthetics with or without steroid for managing chronic low back pain of facet joint origin is fair to good for short- and long-term improvement. The authors found that the best evidence for the use of medial branch blocks is for diagnostic purposes leading to a radiofrequency ablation procedure. In this case, the patient has chronic low back pain which is not radiating into the lower extremities. Previous treatment has included lumbar radiofrequency ablation with six months of low back pain relief. The provider has recommended a lumbar medial branch block to test for radiofrequency ablation procedure pending lumbar magnetic resonance imaging (MRI) results. The current literature recommends lumbar medial branch blocks to test for facetogenic low back pain, and to determine whether the patient is a candidate for treatment with radiofrequency ablation procedure. Based on the available medical records for review and the current evidence based literature, the requested lumbar/sacral facet joint block injection (CPT 64495) 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for advanced wound therapy with placental tissue matrix allograft. Findings:  The physician reviewer found that there is a lack of data in current medical literature supporting the use of placental allografts over standard wound therapies, including periodic debridement, offloading, off weight bearing, contact casting, and possible skin grafting. Given the lack of peer-reviewed published studies available, it is not possible to evaluate the benefits or draw conclusions regarding the efficacy of the requested service. Therefore, advanced wound therapy with placental tissue matrix allograft is not likely to be more beneficial for treatment of the patient's condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested advanced wound therapy with placental tissue matrix allograft 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 services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewer 1 is a D.P.M., board certified in podiatry and is actively practicing. Physician reviewer 2 is a D.P.M., board certified in podiatric surgery and is actively practicing. Physician reviewer 3 is a D.P.M., board certified in podiatric 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Veltassa. Findings:  The physician reviewer found that records provided for review document that this patient presents with a history of hyperkalemia and end-stage renal disease. Treatment has included hemodialysis three times per week as well as recurrent hospitalizations. The patients provider has recommended continued treatment with Veltassa based on the patients positive response since starting therapy in June 2021. The provider also noted that the patient is not a candidate for treatment with Lokelma. In the medical literature, Kovesdy and colleagues found that patients receiving chronic hemodialysis responded well to long-term Veltassa treatment with Veltassa. For these reasons, the requested Veltassa 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 nephrology 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 Palbociclib, 125 mg daily for 21 days, then off for seven days. Finn and colleagues describe Palbociclib as an oral, small-molecule inhibitor of cyclin-dependent kinases (CDKs) 4 and 6. The authors further note that the addition of Palbociclib to letrozole in a phase 2 study significantly improved progression-free survival in women with advanced estrogen receptor-positive and HER2-negative breast cancer. Lee and Ho note that there is emerging data that CDK4 and CDK6 may be effective in metastatic ovarian cancer and reported on a case study in which a patient continued to respond at 30 months to the use of Palbociclib after multiple lines of cytotoxic chemotherapy and hormonal therapy. In this case, the patient has exhausted standard therapies, and current medical literature supports the safety of the requested medication. Therefore, Palbociclib, 125 mg daily for 21 days, then off for seven days, is likely to be more beneficial for treatment of the patient's condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested medication 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 is 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 internal medicine with sub-specialty certification in medical oncology 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 Otezla 30 mg, twice a day. Findings: The U.S. Food and Drug Administration (FDA) approves the use of apremilast (brand name Otezla) for the treatment of moderate-to-severe plaque psoriasis. A study reports that apremilast, given orally at 20 or 30 mg twice daily, seems to be efficacious, safe, and tolerable for patients with moderate-to-severe plaque psoriasis. In this case, the records note that the patient has widespread disease and has failed several topical agents and ultraviolet therapy. Given that the patient is a good candidate for systemic therapy, and as current medical literature supports the use of apremilast in this clinical setting, the requested medication is medically indicated. Therefore, Otezla 30 mg, twice a day, 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.