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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for Stelara (ustekinumab) 90 mg, every 4 weeks.Findings: Two out of three physician reviewers found that Stelara (ustekinumab) 90 mg, every 4 weeks is likely to be more beneficial for the enrollee than any available standard therapy.A large randomized controlled trial by Sandborn and colleagues demonstrated safety and efficacy of Stelara (ustekinumab) for induction and maintenance of remission in patients with moderate-severe Crohns disease that was resistant to anti-tumor necrosis factor (TNF) therapy. A study by Kopylov and colleagues showed that subcutaneous ustekinumab showed a 73.7% response in patients with anti-TNF-resistant Crohns disease, and 80% of responders maintained remission for one year. Tuskey and colleagues indicate that the mechanism of ustekinumab is entirely different than that of anti-TNF medications. In a study by Kopylov and colleagues, a large proportion of patients with inadequate disease control were able to maintain a response with dose escalation to 90 mg of ustekinumab every 4 weeks. Additional studies have shown that a majority of patients in whom Stelara dosing every 8 weeks failed to control symptoms responded to dosing every 4 weeks. Moreover, Battat and colleagues found a Stelara level of at least 4.5 ug/mL is associated with effective disease control. The American College of Gastroenterology guidelines for the treatment of Crohns disease state that, in patients with continued symptoms, the medication dose should be adjusted in order to attempt to optimize therapy. In this case, the patient has symptoms consistent with active Crohns disease on Stelara 90 mg every 8 weeks. The patient has had disease symptoms and objective active disease on colonoscopy, with a low Stelara level of 2.4 ug/mL and lack of anti-Stelara antibodies. A continuation of dosing every 8 weeks or a change to another medication may result in loss of disease control, with complications such as fistula, worsening stricture, bowel obstruction, flare, hospitalization, need for surgery, or other complications. For these reasons, Stelara 90 mg every 4 weeks is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested medication is likely to be more beneficial than any available standard treatment for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer 1, reviewer 2, and reviewer 3 are board certified in board certified in internal medicine with sub-specialty certification in gastroenterology. All reviewers 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:  An enrollee has requested authorization and coverage for Euflexxa injections for both knees.An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The conclusive evidence is limited and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections and in carefully selected cases where everything else has been tried and the options are limited. In this case, the patient has a history of prior viscosupplementation which has provided benefit. Furthermore, the records indicate that the patient is not a candidate for bilateral total knee arthroplasties due to her age and activity level. Therefore, the requested Euflexxa injections for both knees are medically necessary for treatment of the patients medical condition.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 diagnostic laparoscopy. The records provided for review document that this patient has computed tomography (CT) evidence of involvement of the mesenteric root, which is unresectable. Per National Comprehensive Cancer Network (NCCN) guidelines, diffuse infiltration of the root of the mesentery or para-aortic lymph node highly suspicious on imaging is a contraindication to resection. The patient currently has ample radiographic evidence for unresectable and metastatic disease. In this clinical setting, no further testing is indicated. While there is no definitive histologic proof of metastatic disease, further biopsies would only be invasive, adding to the risk of complications and any delays in care required to promote healing and recovery from surgery. All told, the requested diagnostic laparoscopy is not medically necessary for evaluation of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in general 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for sinus tarsi implant with HyProCure device to right and left feet. Findings:  The physician reviewer found that data reports promising results on the efficacy of subtalar arthroereisis in children, its use in adults remains unsubstantiated in the peer-reviewed medical literature. In adults with a less flexible deformity, treatment usually requires other surgical procedures involving the posterior tibial tendon or calcaneal osteotomes to effectively improve the patients condition. Bernasconi and colleagues noted that sinus tarsi pain is the most frequent complication, often requiring removal of the implant. Moreover, the authors found that, poor quality evidence is available in the literaturewith only one comparative non-randomized study (Level II) not providing strong recommendations. All told, the requested sinus tarsi implant with HyProCure device to right and left feet 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 sinus tarsi implant with HyProCure device to right and left feet 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 podiatric surgery and is actively practicing. Physician reviewer 2 is board certified in podiatric surgery and is actively practicing. Physician reviewer 3 is 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Findings:  The physician reviewer found that An enrollee has requested authorization and coverage for vein embolization CPT 37241 for varicocele. Current medical literature supports the use of percutaneous transcatheter scrotal varicocele embolization as a treatment option for men with symptomatic painful varicoceles. Sheehan and colleagues note that varicocele embolization results in a durable reduction in pain scores compared to their preoperative values. The authors further noted that among the measured quality of life parameters, varicocele embolization resulted in significant improvement in return to work, housework, socializing, exercise, sexual relations, and sleeping post-embolization. This treatment modality is associated with fewer surgical complications and high rates of durable treatment of the varicocele. In this case, the records note that the patient has large symptomatic varicocele with pain. While there are several treatment options available, the patients provider has recommended varicocele embolization due to the patients young age and the minimally invasive nature of this treatment. The decision to pursue this treatment is based on discussions between this patient and his physician regarding risks and benefits. Therefore, vein embolization CPT 37241 for varicocele 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 vein embolization CPT 37241 for varicocele is 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for durable medical equipment (DME) wheelchair ramp. Complex regional pain syndrome (CRPS) is a heterogeneous and poorly understood condition that can be provoked by a relatively benign inciting injury (Cutts, et al.). With respect to treatment, various pharmacotherapies and programs to desensitize patients to stimuli have been utilized to manage this condition (Baron, et al.; Kessler, et al.). However, there are few highly effective interventions available in the treatment of patients with CRPS (Duong, et al.; Urits, et al.; Kessler, et al.). The patient in this case, has been diagnosed with arthritis and CRPS. A diagnosis of fibromyalgia is also listed in the available records but was not included on the prescription form. The provider has recommended a power wheelchair to address her dysmobility symptoms and a ramp to address accessibility into the patients residence. The records document the presence of a small threshold that the patients power wheelchair is expected to have difficulty negotiating when entering her residence. It is noted that improper acceleration of the power wheelchair over the threshold risks collision of the wheelchair with the door, which is made of glass. In this clinical setting, the requested wheelchair ramp may be helpful, but it is not supported as medically necessary for treatment of this patients medical conditions based on the current medical literature. For these reasons, the requested wheelchair ramp is not medically necessary for this patient. Final Result: The reviewer determined that the requested equipment 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for revision of bilateral breast augmentation.At issue is whether a revision of bilateral breast augmentation is medically necessary to treat the enrollees gender dysphoria as defined in Health and Safety Code section 1374.72(a)(3)(A).World Professional Association for Transgender Health (WPATH) lists feminizing mammoplasty as a treatment for gender dysphoria. WPATHs Position Statement on Medical Necessity of Treatment states, Non-genital surgical procedures are routinely performed notably, subcutaneous mastectomy in female-to-male transsexuals, and facial feminization surgery, and/or breast augmentation in male-to-female transsexuals. These surgical interventions are often of greater practical significance in the patients daily life than reconstruction of the genitals. WPATH also conclude, These reconstructive procedures are not optional in any meaningful sense but are understood to be medically necessary for the treatment of the diagnosed condition. However, in this case, the patient has already received a breast augmentation in 2020, with good results. There is no documentation that larger implants are indicated or medically necessary. In this patients case, the requested revision of bilateral breast augmentation is not in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested service is not clinically appropriate in terms of type, frequency, extent, site, and duration. Therefore, the requested revision of bilateral breast augmentation 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.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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for Cuvitru subcutaneous immune globulin infusion.Research indicates, Intravenous immunoglobulin (IVIG) therapy is U.S. Food and Drug Administration approved for the immune-mediated peripheral nerve disorders Guillain-Barre syndrome, chronic inflammatory demyelinating polyneuropathy, and multifocal motor neuropathy. The authors also state, Small fiber polyneuropathy may manifest clinically as postural tachycardia syndrome, orthostatic intolerance, orthostatic hypotension, inappropriate sinus tachycardia. Management for autoimmune polyneuropathy includes treating the underlying disease as well as symptomatic relief. Currently, there are multiple reports of treatment success with the use of IVIG for autoimmune small fiber peripheral neuropathy, while randomized controlled trials are underway investigating the efficacy of IVIG. In this case, patient presents with dysautonomia caused by peripheral autonomic dysfunction due to an immune-mediated small fiber polyneuropathy. There is sufficient support for the requested service in this clinical setting. Therefore, the requested Cuvitru subcutaneous immune globulin infusion is medically necessary for treatment of the patients medical condition.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 allergy and immunology 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:  An enrollee has requested authorization and coverage for neuropsychological testing.Schroeder and colleagues state, A neuropsychological consultation can help characterize cognitive deficits, clarify diagnoses, and develop optimal management plans for patients with cognitive issues. The European Federation of Neurologic SocietiesEuropean Neurologic Society (EFNS-ENS) states that cognitive assessment has a key role in the diagnosis and management of dementia. Moreover, Schroeder and colleagues report, Neuropsychological testing is the preferred method for examining and documenting cognitive dysfunction. The authors conclude, Serial assessments can be useful for patients with mild cognitive impairment or in cases where the etiology of cognitive decline is unclear. A 12-month follow-up is often used to determine whether patterns of cognitive decline are consistent with a suspected etiology, identifying conversion of mild cognitive impairment to dementia, or to monitor the rate of cognitive change over time. In this case, the patient reports progressive memory difficulty for the last ten years. Based on the references above, neuropsychological testing is recommended to characterize cognitive deficits and clarify diagnoses. Serial assessments and follow-up testing are done in cases where the etiology of cognitive decline is unclear. Thus, investigating further with repeat neuropsychological testing is medically indicated. Therefore, the requested neuropsychological testing is medically necessary for the evaluation of the patients medical condition.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 neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for anterior cervical discectomy and fusion (ACDF) of C4-7. Although some of the patients symptoms are not explained by her cervical imaging findings such as dizziness, hemibody numbness, trouble walking, and leg weakness, this patient does have pain and numbness radiating from her neck into her arms and hands consistent with cervical radiculopathy. The patients cervical spine MRI explains her radiculopathy as it shows severe bilateral foraminal narrowing at C5-6 and severe left and moderate right foraminal narrowing at C6-7. The patients radicular symptoms have persisted despite several years of nonsurgical treatments. Surgery to address her radiculopathy is therefore reasonable. However, there is a lack of documentation of any foraminal narrowing or any instability at C4-5 to support surgical intervention at that level. Moreover, both of the providers who recommended surgery discussed ACDF at C5-7, and not at the C4-5 level. Given these findings, the requested ACDF from C5-7 is medically necessary for treatment of this patient, while ACDF from C4-5 is not medically necessary for this patient. Final Result: The reviewer determined that a portion of the requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in neurological surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Serostim 4 mg vial. The records provided for review document that this patient has a history of panhypopituitarism following resection of a pituitary adenoma many years ago. The patient has been treated with multiple therapeutic agents including hydrocortisone, levothyroxine, and growth hormone replacement therapy. The provider charted that the patient is experiencing worsening quality of life due to fatigue related to her panhypopituitarism since she stopped taking growth hormone therapy. Her provider has recommended treatment with Serostim. The syndrome of growth hormone deficiency in adulthood is characterized by alterations in body composition and decreased capacity for exercise as well as unfavorable changes in cardiovascular function, and lipid and carbohydrate metabolism (Diez, et al.). Diagnosis of growth hormone deficiency is based on the combination of pituitary disease, hypopituitarism and a decrease in the concentration of insulin like growth factor 1 (IGF-1) or in diminished growth hormone responses to different stimuli. However, in patients with a clear pituitary lesion and a markedly subnormal IGF-1, a stimulation test may not be needed (Alexandraki, et al.). Multiple studies have demonstrated that long-term daily growth hormone replacement therapy can ameliorate or reverse many of the effects of growth hormone deficiency, including beneficial effects on muscle and fat mass, lipid profile, diastolic blood pressure, and bone mass (van Bunderen and Olsson). For these reasons, the requested Serostim 4 mg vial 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.