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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for PROPEL sinus implants utilized during sinus surgery. Findings:  The physician reviewer found that FESS, surgical outcomes can be compromised in the immediate post-operative period by scarring, adhesion formation, and early polyp recurrence. Oral and topical corticosteroid therapy are standard treatments for the maintenance of successful surgical outcomes, the management of post-operative scarring and edema, and the prevention of nasal polyp recurrence. Shen and colleagues report that clinical evidence has demonstrated the safety and efficacy of steroid-eluting sinus implants in the reduction of polyp size, symptom burden, and the need for revision sinus surgery. Hoffman and colleagues note that steroid-eluting sinus implants have been shown in clinical trials to improve postoperative outcomes after functional endoscopic sinus surgery (FESS) by delivering localized, sustained release of corticosteroids directly onto inflamed sinus tissue. The U.S. Food and Drug Administration approves the use of the PROPEL sinus implant for use in adult patients following sinus surgery to maintain patency of the frontal and maxillary sinus ostia. The FDA further notes that the device separates mucosal tissues, prevents obstruction by adhesions, and reduces edema. In this clinical setting, the safety and efficacy of the devices at issue has been established in current medical literature. Therefore, PROPEL sinus implants utilized during sinus surgery were likely to have been more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the PROPEL sinus implants utilized during sinus surgery at issue were 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 requested devices were 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, 2, and 3 are board certified in otolaryngology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Cosentyx 150 mg/mL Sensoready pen. The records provided for review document that this patient presents with a history of moderate-to-severe plaque psoriasis. The patients provider has recommended treatment with Cosentyx. Systemic treatment of psoriasis is indicated when topical treatments fail or do not achieve  sufficient control of disease. The available clinic notes adequately document that the patient has failed treatment with topical therapies, which supports an indication for systemic treatment. The U.S. Food and Drug Administration (FDA) has approved several systemic options for patients with moderate-to-severe psoriasis including non-biologics and biologics such as tumor necrosis factor (TNF)-alpha inhibitors, IL-17 pathway inhibitors, IL-12/23 inhibitors, and IL-23 inhibitors. Medical literatures reported that biologics have been found to be more effective than the non-biologic alternatives. However, there is a lack of data demonstrating that any of the IL-17 or IL-23 inhibitors is more effective than another. The patients provider did not chart support for Cosentyx in lieu of other IL-17 or IL-23 agents. Therefore, the requested Cosentyx 150 mg/mL Sensoready pen 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 dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Inspire device (hypoglossal nerve stimulator). Findings:  The physician reviewer found that As noted in the medical literature, continuous positive airway pressure (CPAP) has demonstrated excellent efficacy in the treatment of patients with OSA, with long-term adherence rates approaching 50%. Although traditional upper airway surgical procedures target the anatomic component of obstruction, upper airway stimulation improves anatomic and neuromuscular pathology. There is adequate evidence in the peer-reviewed literature to support the safety, efficacy, and long-term outcome in the treatment of OSA with hypoglossal nerve stimulation. A meta-analysis by Gillespie and colleagues 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 authors reported that hypoglossal nerve stimulation was found to be safe and effective in a subset of patients with OSA who have failed CPAP with evidence of nonconcentric airway collapse, an AHI between 20 and 50, and a BMI less than 32 kg/m2. The American Academy of Otolaryngology Head and Neck Surgery (AAOHNS) considers upper airway stimulation via the hypoglossal nerve to be a safe and effective second-line treatment for patients with moderate to severe OSA who are intolerant or unable to achieve benefit with CPAP. The records provided for review document that this patients AHI is less than 20 and he had a BMI of 28 kg/m2. The records fail to include documentation that meets the requirements for the requested Inspire device. Based on the available documentation, the requested Inspire device (hypoglossal nerve stimulator) is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services 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 otolaryngology 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 BRCA Panel Plus genetic testing. As noted in the medical literature and National Comprehensive Cancer Network (NCCN) guidelines, BRCA1 and BRCA2 genes are important to test in the setting of a first degree relative with ovarian cancer (Daly, et al.). According to the NCCN guidelines on criteria for genetic testing when suspected to have hereditary breast and ovarian cancer, the patients records should document a first or second degree relative who meets any of the personal history requirements with epithelial ovarian, fallopian tube, or primary peritoneal cancer diagnosis at any age. Based on the NCCN guidelines, this patient meets the criteria to qualify for the BRCA1 and BRCA2 gene testing based on her first degree relative in her sister with ovarian cancer at age 30. In this clinical setting, the performance of genetic testing with BRCA Panel Plus, was consistent with the current recommendations from the NCCN. Accordingly, BRCA Panel Plus genetic testing was likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings: Two of the three physician reviewers found the BRCA Panel Plus genetic testing was likely to have been 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 likely to have been more beneficial for evaluation 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 pediatrics with subspecialty certifications in clinical genetics and clinical biochemical genetics and is actively practicing. Physician reviewer 2 is board certified in clinical genetics and genomics and is actively practicing. Physician reviewer 3 is board certified in medical oncology with subspecialty certification in hematology 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: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for emergency medical services. On review of the available documentation, this patient presented to the emergency department following a visit that morning with recurrent atrial fibrillation after failing outpatient management. The patient demonstrated hemodynamic instability with a blood pressure drop after administration of metoprolol. The patient received a diltiazem infusion for varying heart rates. The patient could not be discharged home with a diltiazem infusion, so he was admitted. Flecainide was added to the patients regimen, and this allowed the patient to be weaned from the diltiazem infusion. According to medical literatures, diltiazem is associated with a shorter time to rate control than metoprolol. The records document that the patient demonstrated hemodynamic instability and required a diltiazem infusion. Consistent with the medical literature, the services provided to this patient from meet the criteria for emergency medical services as defined by California law. Therefore, the services provided to this patient were emergency services.Final Result: The reviewer determined that the services at issue were emergency medical services for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in emergency 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: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for emergency medical services. In this case, the patient was admitted as an inpatient after presenting postoperatively with vomiting and nausea, numbness in the leg, and difficulty ambulating. Her WBC count was 18, and intravenous ceftriaxone was initiated. Following admission, the patient was evaluated by plastic surgery, and her leukocytosis gradually resolved. Due to the patients significant leukocytosis, an emergency medical condition existed from admission. A plastic surgery note indicated that the patient could be discharged to follow-up as an outpatient. As such, two days following admission, an emergency medical condition no longer existed. Therefore, a portion of the services provided were emergency services.Final Result: The reviewer determined that a portion of the services at issue were emergency medical services. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in emergency 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 a MyoPro 2 Motion G orthotic device. Simon and colleagues explain that standard care following brachial plexus trauma includes occupational therapy for functional restoration, including compensatory techniques and measures to mitigate risk of further injury, in conjunction with close monitoring for evidence of reinnervation, which dictates whether surgical interventions may be indicated. Noland and colleagues report that surgical interventions include neurolysis, nerve grafts, and nerve transfers, ideally beginning within six months of injury, and the use of tendon transfers and functioning free muscle transfers. Multiple surgeries may be needed to effectuate a good outcome. However, Shanina and colleagues note that controlled trials are still needed to confirm and optimize surgical therapeutic strategies. Overall, brachial plexus injuries remain frequently associated with poor functional outcomes. Despite these suboptimal outcomes, there is no established role of myoelectric upper limb orthoses in this clinical setting. Pundik and colleauges report that while use of MyoPro in motor learning-based therapy resulted in clinically significant gains with a relatively short duration of in-person treatment, further studies are warranted. Limitations of the study included small sample size, no blinding, and no comparison group. Current medical literature related to myoelectric upper limb orthoses remains preliminary, particularly with respect to long-term outcomes data such as safety and adverse sequelae, and there is a lack of data  proving clinically significant health or functional benefits. Currently available myoelectric upper limb orthoses are bulky devices that can potentially cause or exacerbate edema, skin injuries, musculoskeletal injuries, neural traction and pain. Given that further well-designed studies of an unbiased nature are required to better understand the adoption of these types of devices in clinically meaningful settings, to determine whether function is improved, and to establish long-term safety, the requested device is not medically indicated. Therefore, a MyoPro 2 Motion G orthotic device is not medically necessary for the 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 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 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 left cervical transforaminal epidural steroid injections at C5-6 and C6-7. Multiple prospective randomized studies have demonstrated the benefit of transforaminal epidural steroid injections to improve pain and disability in patients with cervical foraminal stenosis. The records document that this patient has cervical foraminal stenosis at C5-6 and C6-7 on the left. Based on the records, there is evidence that the patients medical condition is generated by the foraminal stenosis at C5-6 and C6-7. However, the confidence in this assessment is confounded by the patients history of thoracic outlet syndrome, which could produce similar symptoms. There are therapeutic benefits to treatment with cervical transforaminal epidural steroid injections in the treatment of radicular symptoms. In addition, cervical epidural steroid injections can help determine whether a patients pain is significantly reduced when performed at a specific level. This has implications for future treatment including possible surgical interventions. Given this support, the left cervical transforaminal epidural steroid injections at C5-6 and C6-7 were medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were 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 physical medicine and rehabilitation 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

Findings:  The physician reviewer found that An enrollee has requested authorization and coverage for Rinvoq 15 mg extended release (ER) tablets. In this case, the records show that the patient has been tried on several biologic agents in the past. However, it is not clear that the patient has had dose optimization or that the clinical criteria for therapy failure were truly met. One reasonable path is to reintroduce previously used agents such as vedolizumab alone or in combination with another agent or immunomodulator. During retreatment there is the opportunity for therapeutic drug monitoring, prospective assessment as to whether therapy is truly failing, and for using objective endoscopic, radiologic, and biomarker data to determine success or failure. While notes reported that the patient has not yet been exposed to Janus kinase (JAK) inhibitor therapy, there is a lack of data in current medical literature from phase 3 studies regarding their use in the treatment of Crohn's disease. Therefore, Rinvoq 15 mg ER tablets are not 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 Rinvoq 15 mg ER tablets are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Findings:  The physician reviewer found that The patient has requested authorization and coverage for sildenafil 25 mg tablets. The records provided for review indicate that this patient is status post radical prostatectomy for treatment of prostate cancer. The patient has been treated with sildenafil, which the provider states has been beneficial for the patients neuropathic issues including urinary and bowel changes. The provider has recommended continued treatment with sildenafil. However, the available clinical documentation does not adequately define the patients symptomatology or identify specific improvements as a result of this medication. Furthermore, although medications such as solifenacin have been shown to improve overactive bladder, there is markedly less literature demonstrating any benefit in neurogenic bowel and bladder complaints with the use of sildenafil. Overall, there is a lack of documentation of specific symptoms being treated, improvement in those symptoms as a result of sildenafil, and medical literature support for continued treatment with sildenafil for these conditions. Given these findings, the requested sildenafil 25 mg tablets 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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for platelet-rich plasma (PRP) treatment. Findings:  The physician reviewer found that Results of numerous quality trials on the efficacy of PRP for treatment of chronic lateral epicondylitis have been highly variable and lack adequate data to support their use in lieu of standard therapies. Linnanmaki and colleagues found that PRP injections did not improve pain or function at one year follow-up in patients with lateral epicondylitis compared with patients who received a saline injection. In addition, de Vos and colleagues noted that PRP injections were not efficacious in the management of patients with chronic lateral elbow tendinopathy. Simental-Mendia and colleagues performed a systematic review and meta-analysis of randomized placebo-controlled clinical trials on the safety and efficacy of PRP injections in the treatment of patients with chronic lateral epicondylitis. The authors concluded that PRP injections have not been demonstrated to be superior to placebo for relieving pain and joint functionality in patients with chronic lateral epicondylitis. For this patient with bilateral lateral epicondylitis, the medical literature does not support an indication for the requested PRP injections. Given these findings, the requested PRP treatment 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 PRP treatment 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 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.