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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for 45-minute weekly acupuncture services.Vickers and colleagues state, Acupuncture is effective for the treatment of chronic musculoskeletal, headache, and osteoarthritis pain. Moreover, Vickers and colleagues concluded that acupuncture is effective for the treatment of chronic pain and is therefore a reasonable referral option. In this case, the patient reported prior acupuncture care as beneficial in reducing symptoms and improving activities of daily living. However, there are no pre-acupuncture and post-acupuncture functional baselines documented for comparison purposes. After an extensive number of prior acupuncture sessions were completed, the records do not document measurable, progressive, significant, objective functional improvement to support the necessity of additional acupuncture services. Additionally, there is no clear documentation indicating whether the patient is currently undergoing an independent exercise program. Therefore, 45-minute weekly acupuncture services are not medically necessary for treatment of the patients medical condition. 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 oriental 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 brand name Lyrica. The records provided for review document that this patient has a history of metastatic breast cancer with bone pain and lumbar radiculopathy. The patients pain has been managed with a combination of opioid therapy and brand name Lyrica. The patient has been treated with pregabalin 50 mg twice daily, but this provided inadequate relief. The provider reported that the patients pain is controlled with a regimen including brand name Lyrica, Fentanyl patch, hydrocodone, and Calcitonin spray. Per the U.S. Food and Drug Administration (FDA), A generic drug is a medication created to be the same as an already marketed brand-name drug in dosage form, safety, strength, route of administration, quality, performance characteristics, and intended use. These similarities help to demonstrate bioequivalence, which means that a generic medicine works in the same way and provides the same clinical benefit as its brand name version. The FDA regulates the production of generic medications and requires manufacturers to meet strict quality standards to ensure the generic medication works just as well as the branded version. In this patients case, the lack of effect of the pregabalin, the generic formulation of Lyrica, is more likely attributable to dosing effects since the active ingredient in both the brand name and generic formulations is identical. For these reasons, the requested brand name Lyrica is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested brand name 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 anesthesiology with subspecialty certification in pain management 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 reimbursement and prospective authorization and coverage for Optune Plus Transducers Tumor Treating Fields (TTF) services.Optune has been approved by the U.S. Food and Drug Administration (FDA) for the treatment of recurrent glioblastoma. Approval was based on results of a clinical trial that randomized 237 patients to TTF or chemotherapy. Similar survival was observed in the two arms, and TTF therapy was associated with lower toxicity and improved quality of life. A subsequent open-label randomized trial in patients with newly diagnosed glioblastoma showed prolonged progression-free and overall survival in the group assigned to TTF when used in combination with post-radiation temozolomide. At this time, however, there is a lack of data supporting retreatment with Optune after progression with first-line use of Optune. This patient has already been treated with Optune, with progression. Therefore, Optune Plus Transducers TTF services provided and forward were not and are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were not and 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 sub-specialty certification in medical oncology 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 transcatheter mitral valve repair (MitraClip procedure). This patient presents with transposition of the great arteries status post balloon atrial septostomy, Blalock-Taussig shunt, bidirectional Glenn shunt, and completion of hemi-mustard operation. A recent transthoracic echocardiogram reportedly demonstrated severe dilation of the right ventricle and a severely decreased systolic function. The patients provider has recommended transcatheter mitral valve repair with MitraClip. Based on current peer-reviewed medical literature, the requested MitraClip procedure is likely to be more beneficial for treatment of the patient than any available therapy. There are ample data demonstrating that the MitraClip procedure is safe and effective in this patients clinical scenario (Nickenig, et al.). In this case, the patient has complex congenital heart disease. He has undergone previous cardiothoracic surgical procedures and he is an unacceptably high surgical risk. The MitraClip is a transcatheter procedure recommended as a safer option to correct this patients tricuspid regurgitation, as he has with severe valve disease, advanced heart failure symptoms, and limited options for treatment. Therefore, the requested transcatheter mitral valve repair (MitraClip procedure) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the requested transcatheter mitral valve repair (MitraClip procedure) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in internal medicine with subspecialty certifications in cardiovascular disease and cardiac electrophysiology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in cardiovascular disease and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certifications in cardiovascular disease and cardiac electrophysiology 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 modafinil (Provigil). Findings:  The physician reviewer found that central hypersomnias are diseases manifested in excessive daytime sleepiness and that the Multiple Sleep Latency Test (MSLT) serves as an objective diagnostic method for idiopathic hypersomnias. The authors further note that for symptomatic therapy of excessive daytime sleepiness, the central nervous system stimulant modafinil seems to work well in most cases. In this case, the patient has a diagnosis of idiopathic insomnia based on MSLT results showing sleep latency of 3.5 minutes without sleep onset rapid eye movement (SOREM). In this clinical setting, the requested medication is medically indicated. Therefore, modafinil (Provigil) 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 internal medicine with sub-specialty certification in sleep 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 removable foot insert, molded to patient model, longitudinal/metatarsal support (HCPCS code L3020).At issue is whether the removable foot insert, molded to patient model, longitudinal/metatarsal support (HCPCS code L3020) is medically necessary for the treatment of the patients medical condition. For children on Medi-Cal, care is considered medically necessary if it is needed to: (1) prevent disease, disability, and other health conditions or their progression; (2) prolong life; (3) promote physical and mental health and efficiency; or (4) correct or ameliorate any physical or behavioral conditions.According to Carr and colleagues, custom orthotics are used to correct the biomechanical abnormality, reduce loss of medial column of feet when weightbearing, and to allow for pain-free ambulation. In this case, the records document a symptomatic pes planus foot structure along with abnormalities of gait. During the most recent examination, the patient is noted to have foot pain caused by ill-fitting custom orthotics. It is noted that this patients foot has grown considerably since his last pair of orthotics and he needs a new pair of custom orthotics. Therefore, removable foot insert, molded to patient model, longitudinal/metatarsal support (HCPCS code L3020) is medically necessary for treatment of the patients medical condition. Moreover, a new pair of orthotics would correct or ameliorate the patients pes planus.Final Result: The reviewer determined that the requested equipment 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 podiatry 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 reimbursement for the hospital stay.According to Tang and colleagues, acute cholecystitis can be managed with cholecystectomy as a day surgery procedure, or with a short observation stay. In this case, the patient did not have protracted hypotension, tachycardia, or other stigmata of severe volume depletion or sepsis. Additionally, imaging performed just after presentation was not consistent with pathology such as biliary obstruction or choledocholithiasis, gallbladder perforation, pancreatitis, or complications of gallstone disease. Moreover, the patient did not have acute cholangitis, active gastrointestinal bleeding, gastrointestinal perforation, peritonitis, abscess, sepsis, or other gallbladder or biliary complications warranting inpatient level of care. The patient was appropriately evaluated for gallbladder disease, and her disease was fully addressed with laparoscopic cholecystectomy, which could have been performed without acute inpatient level of care, at the observation level of care. For these reasons, the hospital stay provided was not medically necessary for the treatment of the patients cholecystitis.Final Result: The reviewer determined that the services at issue were 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Vimpat 100 mg tablet (quantity 60, day supply 30). Researchers note that while the mainstay treatment strategy for seizures is medication management, much like the prescription of any other pharmaceutical agent, a clinician must balance efficacy with adverse events, and provide consideration for cost, drug interactions, patient preference, and availability with the focus predominantly on an individualized approach, with patient autonomy at the forefront. The authors further note that lacosamide (brand name Vimpat) is used as monotherapy or adjunct therapy for focal-onset seizures in patients aged four years and up, and tends to be tolerated decently well, with dizziness, ataxia, and nausea being the most typically encountered adverse effects. Researchers note that it is important to understand drug risks and benefits and that there are both medication and patient-related factors that influence appropriate drug selection, with the goal being to provide the best chance for seizure freedom with the lowest risk for potential side effects. Medical literature report that for focal epilepsy, lacosamide may be considered to decrease seizure frequency. In this case, the patients seizures have not been controlled with Keppra. The provider has recommended Vimpat, taking into account the drug risks versus benefits, with the goal of achieving the best chance for this patient for seizure freedom with the lowest risk for potential side effects. Given that current medical literature endorses an individualized approach in seizure management with patient autonomy and preference is at the forefront, the requested medication is medically indicated. Therefore, Vimpat 100 mg tablet (quantity 60, day supply 30) 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

An enrollee has requested authorization and coverage for Xeljanz. In the treatment of alopecia areata, current medical literature shows that the higher the percentage of involvement, the more aggressive the treatment. Strazzulla and colleagues note that a published algorithm recommends topical and oral steroids with minoxidil, sensitization, Janus kinase (JAK) inhibitors, or prostheses in cases with 50% or greater scalp involvement. For cases with less than 50% scalp involvement, the algorithm recommends immunotherapy. In this case, visit notes reported that the patient was completely devoid of scalp, facial, and body hair, and had not responded to typical therapies. In this clinical setting, current medical literature supports the use of JAK inhibitors to treat the patients condition systemically. Therefore, Xeljanz is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested Xeljanz 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 dermatology 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:  An enrollee has requested authorization and coverage for Xolair injection.According to Zuberbier and colleagues, the diagnostic work-up of chronic spontaneous urticaria is diagnosed by: (i) excluding differential diagnoses; (ii) assessing disease activity, impact and control and (iii) identifying triggers of exacerbation or, where indicated, any underlying causes. The first step in diagnosis is a thorough history, followed by a physical examination of the patient. Additionally, according to Bernstein and colleagues, acute urticaria and angioedema will usually resolve spontaneously. Bernstein and colleagues state, Common causes of acute urticaria and angioedema, including medications and foods, should be identified by a detailed history and eliminated, if possible. For treatment of acute urticaria and angioedema, antihistamines are efficacious in most cases and recommended as first-line therapy. The authors noted, In patients with poor response to antihistamines, a brief course of oral corticosteroids might also be required while attempting to eliminate suspected triggers and develop an effective treatment plan. In this case, it is not specified how long and what dosage of conservative therapies, such as oral antihistamines, have been utilized and failed. Additionally, urticarial lesions have not been observed in physical examinations. Moreover, the records do not demonstrate that underlying causes have been eliminated. Therefore, the requested Xolair injection is not medically necessary for treatment of the patients medical condition.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 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. Findings:  The physician reviewer found that
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 in both knees (HCPCS code J7323).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 current 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, there is a history of good extended response to prior viscosupplementation. Furthermore, the patients options are limited. The patient has tried and failed other conservative treatments, with the alternative being total knee arthroplasties. Therefore, Euflexxa injections in both knees (HCPCS code J7323) 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.