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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for albuterol sulfate HFA 90 mcg/actuation aerosol inhaler. Findings: Based on the available information, the requested albuterol sulfate HFA 90 mcg/actuation aerosol inhaler is not medically necessary for treatment of this patient. The U.S. Food and Drug Administration (FDA) has approved albuterol for the management of patients with asthma, chronic obstructive pulmonary disease (COPD), or airway bronchoconstriction. However, the records provided for review do not support the presence of one or more of the FDA approved diagnoses to support an indication for treatment with albuterol. Per the Global Initiative for Asthma (GINA), there is a lack of data demonstrating that the patients mask donning and bronchospasm or bronchoconstriction will improve with albuterol treatment. For these reasons, the requested albuterol sulfate HFA 90 mcg/actuation aerosol inhaler 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 internal medicine with subspecialty certifications in pulmonary diseases and critical care medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intensity modulated radiation therapy (IMRT). Applying the recommendations from guidelines, IMRT has not been demonstrated to yield superior patient health outcomes when compared to standard whole breast radiotherapy utilizing 3D conformal radiation therapy in the treatment of this patients breast cancer. Furthermore, high quality clinical outcomes published in the medical literature and expert-consensus national guidelines. Based on the peer-reviewed medical literature and current guidelines, the patient could have been treated with hypo fractionated 3D conformal radiation therapy, which has been associated with equivalent safety and efficacy this patients clinical situation. Therefore, the IMRT was 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 services at issue were 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 radiation oncology and is actively practicing. Physician reviewer 2 is board certified in radiation oncology and is actively practicing. Physician reviewer 3 is board certified in radiation 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing (CPT 81162 and 81307). Findings:  The physician reviewer found that patients with BRCA1 mutations can be at increased risk for breast, ovarian, cervical, uterine, pancreatic, gastric, and prostate cancers. In addition, BRCA2 mutations can increase a patients risk for breast, ovarian, gall bladder, bile duct, prostate, pancreatic, and gastric cancers. In the event the BRCA tests are negative, there is still a possibility of hereditary predisposition from another gene defect. This patient has a history of one a maternal grandmother with breast cancer, but there is no other history that indicates the presence of a cancer syndrome. In this clinical setting, the recommended course of action includes genetic counseling followed by ordering the appropriate testing. Based on the available documentation, the genetic testing (CPT 81162 and 81307) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings: Two of the three physician reviewers found the genetic testing (CPT 81162 and 81307) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for 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 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: . The patient has requested authorization and coverage for Orencia. The American College of Rheumatology guideline for the treatment of rheumatoid arthritis does not recommend a target synthetic disease-modifying antirheumatic drugs (DMARD), such as Xeljanz or Rinvoq, over a biologic DMARD, such as Orencia, when adjusting treatment to optimize control of rheumatoid arthritis disease symptoms. Ikeda and colleagues describe the overlap syndrome between rheumatoid arthritis and systemic lupus erythematosus (SLE) as rhupus. The authors report that in a study to assess the efficacy of Orencia for the treatment of rhupus, disease activity as measured by the Clinical Disease Activity Index (CDAI) significantly decreased between baseline and 12 weeks and remained low through 24 weeks when treated with Orencia. The authors further noted that the levels of immunoglobulin G and anti-DNA antibody significantly decreased between baseline and 24 weeks. The authors concluded that Orencia is likely to be efficacious in patients with rhupus who have arthritis refractory to methotrexate and may have a moderate effect in reducing abnormal antibody production in persons with rheumatoid arthritis and SLE overlap syndrome. In this clinical setting, given that current medical literature supports the use of Orencia for the treatment of rheumatoid arthritis with SLE as an overlap syndrome, the requested medication is medically indicated. Therefore, Orencia 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 rheumatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Findings:  The physician reviewer found that The patient has requested authorization and coverage for hydrocodone/acetaminophen 10 mg/325 mg (30 tablets/month). On determining when to initiate or continue opioids for chronic pain, Dowell and colleagues report, Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate.  The authors further note, Before starting opioid therapy for chronic pain, clinicians should establish treatment goals with all patients, including realistic goals for pain and function, and should consider how opioid therapy will be discontinued if benefits do not outweigh risks. Clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety. The Federation of State Medical Boards (FSMB) strongly recommends prescribers use opioid therapy for chronic pain that is not cancer-related, or part of palliative care or end-of-life care, only when non-opioid and non-pharmacological options have not been effective and maintain opioid dosage as low as possible and continue only if clear and objective outcomes are being met. In this case, the patient has a diagnosis of lumbar facet and myofascial pain. The patient has reported past relief from lumbar radiofrequency lesioning (RFL). The patients pain management provider has recommended nonpharmacological modalities and does not note that opioid therapy is indicated at this time. While the guidelines are clear that opioid therapy may be initiated for patients for whom the benefit to risk ratio is favorable, in this case, the patient reports using alcohol for pain relief and the records document a history of post-traumatic stress disorder (PTSD) and major depressive disorder. Concurrent usage of alcohol with opioid therapy increases the risk of adverse reactions, and behavioral health disorders are also a known risk factor for opioid related complications. Given that this patient is being treated with non-pharmacological methodologies in a manner consistent with current medical literature, the requested medication is not medically indicated. Therefore, hydrocodone/acetaminophen 10 mg/325 mg (30 tablets/month) is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service 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

Findings:  The physician reviewer found that An enrollee has requested authorization and coverage for bariatric surgery.According to Aminian and colleagues, the American Society for Metabolic and Bariatric Surgery (ASMBS) recommends, For patients with BMI 30 to 35 kg/m2 and obesity related comorbidities who do not achieve substantial, durable weight loss and comorbidity improvement with reasonable nonsurgical methods, bariatric surgery should be offered as an option for suitable individuals. In this population, surgical intervention should be considered after failure of nonsurgical treatments. Additionally, the medical literature reflects that metabolic and bariatric surgery is not indicated for patients with BMI less than 30 kg/m2. Additionally, for patients with BMI from 30 kg/m2 to 35 kg/m2, bariatric surgery is generally only considered when the patients have type 2 diabetes. In this case, the records do not document clinically severe or morbid obesity with a BMI that is at least 35 kg/m2 to 39.9 kg/m2 with at least one serious obesity comorbid condition such as diabetes, hypertension or sleep apnea. This patient has a normal hemoglobin A1C level, and his BMI is less than 30 kg/m2. The patient does not meet nationally accepted criteria for bariatric surgery. Therefore, the requested bariatric surgery is not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested service is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for revision top surgery. Chest surgery in transgender male minors is a common treatment for gender dysphoria. The World Professional Association for Transgender Health (WPATH) states, Chest surgery in female-to-male patients could be carried out earlier, preferably after ample time of living in the desired gender role and after one year of testosterone treatment. Medical literature reported that chest surgery in transgender youth and males is a safe and effective treatment for gender dysphoria, noting, Chest dysphoria was high among presurgical transmasculine youth, and surgical intervention positively affected both minors and young adults. Given these findings, professional guidelines and clinical practice should consider patients for chest surgery based on individual need rather than chronologic age. In this case, the patient has a diagnosis of gender dysphoria whose provider has recommended revision surgery following a mastectomy. In this patients case, revision top surgery is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested service is clinically appropriate in terms of type, frequency, extent, site, and duration. The requested service is not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Therefore, the requested revision top surgery is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Entyvio 300 mg. Entyvio has been demonstrated to be safe and effective for the treatment of patients with ulcerative colitis (Rubin, et al.). One study reported that Entyvio was more effective than Humira at 52 weeks, and safer as well (Sands, et al.). The American Gastroenterological Association (AGA) guidelines state that, patients, particularly those with less severe disease, who place higher value on the potential safety of medications, and a lower value on the relative efficacy of medications, may reasonably choose vedolizumab (Feuerstein, et al.). The AGA guidelines support treatment with Entyvio for induction of remission in ulcerative colitis (Feuerstein, et al.). Entyvio has shown efficacy for the treatment of ulcerative colitis in high-quality studies, including randomized controlled trials (Mosli, et al.; Lin, et al.). The records provided for review document that this patient has ulcerative colitis that failed to improve with Uceris and mesalamine. The patients symptoms have been adequately managed with Entyvio. The provider has recommended continued treatment with Entyvio. Given this patients positive response to Entyvio, discontinuation or change to another agent may result in uncontrolled ulcerative colitis and disease complications. For these reasons, the requested Entyvio 300 mg 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 gastroenterology 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 Humira 40 mg/0.4 mL pen, quantity of four per 28 days. There is a lack of evidence in current medical literature supporting the use of the requested medication regimen for the treatment of enthesitis-related arthritis subtype of juvenile idiopathic arthritis and juvenile ankylosing spondylitis. Mistry and colleagues note that management of enthesitis-related arthritis includes NSAIDs with physical therapy. The American College of Rheumatology/Arthritis Foundation guideline for the treatment of juvenile idiopathic arthritis reports that, In children and adolescents with active sacroiliitis despite NSAIDs, adding a tumor necrosis factor inhibitor (TNFi) is strongly recommended over continued NSAID monotherapy. Burgos-Vargas and colleagues note in a randomized, double-blind, placebo-controlled multicenter of pediatric patients with enthesitis-related arthritis treated with a maximum Humira dosage of 40 mg every other week, Humira reduced the signs and symptoms of enthesitis-related arthritis at week 12, with improvement sustained through week 52 compared to placebo. In a double-blind, placebo-controlled randomized trial with adalimumab for the treatment of juvenile onset ankylosing spondylitis by Horneff and colleagues, study participants also received Humira every other week. The authors noted that the use of Humira resulted in a significant decrease in juvenile ankylosing spondylitis disease activity parameters at week 12, compared to placebo, was even more pronounced at week 24. In this case, the patient is currently on Humira, a TNFi, at the dosage and frequency approved by the U.S. Food and Drug Administration (FDA). While weekly dosing of Humira may be used for the treatment of Crohns disease, in this case, the records note that the patients inflammatory bowel disease symptoms are controlled on Humira every other week. In this clinical setting, given the lack of evidence in current medical literature supporting a dose escalation for the treatment of enthesitis-related arthritis in pediatric patients, the requested medication regimen is not medically indicated. Therefore, Humira 40 mg/0.4 mL pen, quantity of four per 28 days, is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication regimen 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 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 authorization and coverage for positron emission tomography (PET) scan with computed tomography (CT) for attenuation. While current guidelines from the National Comprehensive Cancer Network (NCCN) recommend a chest CT first, Basu and colleagues report that increasingly, integrated PET/CT imaging is playing a crucial role in the assessment of patients with known or suspected malignant pleural mesothelioma. The authors further note that the major role of PET/CT at present appears to be in the preoperative disease staging, response to treatment assessment, and post-treatment disease surveillance of mesothelioma, and that in all these three areas, PET/CT convincingly shows better results than conventional anatomical imaging alone. Therefore, PET scan with CT for attenuation is likely to be more beneficial for evaluation of the patient's condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested PET scan with CT for attenuation 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 service 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for removal of benign growths on left cheek and under left breast. This patients records document the presence of a left lower cheek lesion that has increased in size over the past year and a lesion under the left breast. As noted in the medical literature, the removal of benign seborrheic keratoses is not supported as medically necessary for treatment of this patient. The growths are not blocking an orifice, causing pain, or infection. The photographs and records support that these are normal tumors that are benign. Therefore, the requested removal of benign growths on left cheek and under left breast is not medically necessary for treatment of this patient. The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; or (2) to create a normal appearance, to the extent possible. Benign growths are developmental abnormalities. Based on the available documentation, the requested removal of the benign growths is not being requested to improve function or address infection. Moreover, the requested benign tumor removal will not create a more than minimal improvement in the patients appearance. Given these findings, the requested removal of benign growths on left cheek and under left breast is not reconstructive in nature for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary and not reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. 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.