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

Findings:  The physician reviewer found that The patient has requested authorization and coverage for arthroscopic procedure to the right knee. On review of current peer-reviewed medical literature, there is a lack of support for the requested knee arthroscopy for treatment of this patients right knee chondromalacia, chondral fissuring, and osteoarthritis of the patellofemoral joint. As noted by the American Academy of Orthopaedic Surgeons (AAOS), there is strong evidence against performing arthroscopy with lavage and/or debridement in patient with primary diagnosis of symptomatic osteoarthritis of the knee. Brignardello-Petersen and colleagues reported on a systematic review comparing conservative management versus knee arthroscopy in patients with degenerative knee disease. The authors concluded that patients who underwent knee arthroscopy did not show important benefits in pain or function at long-term follow-up. Rixe and colleagues found that the most effective and strongly supported treatment modality for patients with patellofemoral pain syndrome is a combined physiotherapy program, including strength training of quadriceps, hip abductors, and stretching of the quadriceps muscle group. Based on the medical literature, surgical treatment of this patients right knee patellofemoral chondromalacia is not indicated. Therefore, the requested arthroscopic procedure to the right knee 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for transabdominal cerclage procedure. According to current American College of Obstetricians and Gynecologists (ACOG), The inability of the uterine cervix to retain a pregnancy in the second trimester is referred to as cervical insufficiency. Per the ACOG recommendations, this patients clinical history and presentation supported treatment with a transvaginal cervical cerclage. However, the patient elected to undergo transabdominal cervical cerclage, which is a procedure reserved for patients who have failed transvaginal cerclages or have anatomic challenges that makes a transvaginal cerclage impossible. In addition, transabdominal cervical cerclage carries greater risks than transvaginal cerclage. Based on the available medical records, this patient does not meet the clinical criteria for a history-indicated transabdominal cerclage. For these reasons, the transabdominal cerclage procedure was not medically necessary for treatment of this patient.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 obstetrics and gynecology 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 reimbursement for DecisionDx-Melanoma genetic testing. As noted in the medical literature, the DecisionDx-Melanoma test is a 31 gene assay of an individual patients melanoma cells that classifies melanoma into either Class 1 or Class 2, with a differing prognosis at five years. The National Comprehensive Cancer Network (NCCN) does not recommend routine use of the DecisionDx-Melanoma genetic testing for evaluation of patients with malignant melanoma, as in this patients clinical setting. Specifically, there is a paucity of data demonstrating that the use of the DecisionDx-Melanoma assay to direct treatment planning improves patient health outcomes when compared to standard risk profiling. Currently, DecisionDx-Melanoma testing is not recommended to help direct clinical decisions, such as the need for sentinel node biopsy and/or adjuvant therapy. Given these findings, the DecisionDx-Melanoma genetic testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Findings: Three of the three physician reviewers found the DecisionDx-Melanoma genetic testing 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 evaluation 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 dermatology and is actively practicing. Physician reviewer 2 is board certified in dermatology and is actively practicing. Physician reviewer 3 is board certified in dermatology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Selzentry tablets. Findings: There is a lack of evidence in current medical literature supporting the use of maraviroc as a therapeutic regimen for post-COVID symptoms. The Centers for Disease Control (CDC) states regarding the management of post-COVID conditions, Some treatments have been offered that lack evidence of efficacy or effectiveness, and could be harmful to patients. Healthcare professionals should inquire about any unprescribed medications, herbal remedies, supplements, or other treatments that patients may be taking for their post-COVID conditions. Given the lack of clinical studies on the efficacy of maraviroc in this clinical setting, the requested medication is not medically indicated. Therefore, Selzentry tablets are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in infectious disease 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 Repatha (evolocumab) SureClick Auto-injector 140 mg/ml, every two weeks. The American College of Cardiology has developed an expert consensus decision pathway regarding the role of non-statin therapies for LDL lowering for management of atherosclerotic cardiovascular disease risk. Alirocumab and evolocumab (Repatha) may be considered if the goals of therapy have not been achieved on maximally tolerated statin and ezetimibe in higher risk patients with clinical atherosclerotic cardiovascular disease or familial hypercholesterolemia. In this case, the patient had no intolerance to these drugs and has achieved an LDL level of 43 mg/dL, which is consistent with published guidelines from the American Heart Association and the American College of Cardiology for target LDL levels. There is a lack of randomized clinical trials that demonstrate that further lowering of the LDL level beyond 70 mg/dL or targeting a lower LDL particle number using proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors such as Repatha will improve clinical outcomes. Therefore, Repatha (evolocumab) SureClick Auto-injector 140 mg/ml, every two weeks is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease 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 Monovisc injection. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as routine treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patient has a history of lasting benefit from viscosupplementation with Monovisc injections with excellent results. The patient did not adequately respond to treatment with physical therapy or NSAIDs. The provider has recommended a repeat injection of Monovisc into the right knee. In this clinical setting, the medical literature supports treatment with viscosupplementation for this patient. Accordingly, the requested Monovisc injection is medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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

Findings:  The physician reviewer found that The patient has requested authorization and coverage for discectomy at vertebrae L5-S1. The records document that this patients complaints include back pain with intermittent radicular pain every two to three years. Review of a magnetic resonance imaging (MRI) study showed some lateral recess stenosis. However, the MRI did not reveal any evidence of severe stenosis or a significant herniated disc to justify discectomy surgery (Motiei-Langroudi, et al.). In addition, the patient has an elevated hemoglobin A1C, which is a contraindication for spine surgery. Hikata and colleagues noted that diabetes mellitus is a risk factor for surgical site infection (SSI), which is a serious complication after spinal surgery. The authors suggest lowering a patients hemoglobin A1C to under 7% before considering surgical intervention. This patients provider has advised continued treatment with conservative care, which is consistent with the recommendations in the medical literature. Given lack of herniated disc on MRI and the patients highly elevated hemoglobin A1C, the requested discectomy at vertebrae L5-S1 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Pradaxa 150 mg twice daily. The records provided for review document that this patient has a history of DVT and saddle pulmonary embolism. The patient has been successfully and safely maintained on Pradaxa since his diagnosis of DVT and saddle pulmonary embolism 2019. The patients provider has recommended continued treatment with Pradaxa. The U.S. Food and Drug Administration (FDA) has approved Pradaxa for the treatment and prevention of DVT and pulmonary embolism in patients at risk for recurrence. In addition, the American College of Chest Physicians (ACCP) and American Family Physicians (AFP) support treatment with Pradaxa for the prevention and treatment of DVT or pulmonary embolism (Wigle, et al.). Schulman and colleagues found that Pradaxa was effective in the extended treatment of venous thromboembolism and carried a lower risk of major or clinically relevant bleeding than warfarin. Moreover, Ageno and colleagues found that in phase III studies, Pradaxa was as effective as, and significantly safer than warfarin. Given this support, the requested Pradaxa 150 mg twice daily 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 certifications in medical oncology and hematology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Intracept spine procedure. The U.S. Food and Drug Administration (FDA) has approved the Intracept procedure for use in conjunction with radiofrequency generators for the ablation of basivertebral nerves of the L3 through S1 vertebrae. The FDA has endorsed use of the Intracept procedure for patients with chronic low back pain of at least six months duration that has not responded to at least six months of conservative care accompanied by features consistent with Type 1 or Type 2 Modic changes on an MRI. This patient has history of spondylosis without myelopathy or radiculopathy, lumbar region, disease of the musculoskeletal system and connective tissue, and other intervertebral disc degeneration, lumbar region. The patients MRI showed mild endplate spurring at L2-3 and L3-4 levels along with advanced spondylosis from L1-2 through L4-5 and mild spondylosis at L5-S1. However, there is a lack of documentation of findings supportive of the spinal vertebral bodies as being the overwhelming primary generators of the patients chronic persistent pain. There was also plausible occasional nerve root generated/painful radiculitis evident. There is a paucity of current studies demonstrating that the Intracept procedure is likely to be more beneficial for this patient than standard available treatment modalities. Therefore, the requested Intracept spine procedure 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 Intracept spine procedure 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 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 orthopedic surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Monovisc injection in the right knee. Findings: Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as routine treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patient does not have history of treatment with prior viscosupplementation. However, the options have been tried including non-steroidal anti-inflammatory drugs (NSAIDs), physical therapy, cortisone injection, platelet rich plasma, and knee aspiration without significant relief. For these reasons, the requested Monovisc injection in the right knee is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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 patients parent has requested authorization and coverage for Palforzia. Findings: The records provided for review document that this patient has a history of peanut allergy. A study noted that, In patients with peanut allergy, high-certainty evidence shows that available peanut oral immunotherapy regimens considerably increase allergic and anaphylactic reactions over avoidance or placebo, despite effectively inducing desensitization. The authors concluded that, Safer peanut allergy treatment approaches and rigorous randomised controlled trials that evaluate patient-important outcomes are needed. On review of the available records, there is a lack of support for treatment with Palforzia for this patient. Although oral immunotherapy has been demonstrated to be an acceptable therapy to attempt to induce desensitization in well-selected patients, there remains a higher risk of adverse reactions while undergoing oral immunotherapy. The records do not support that this patient meets the criteria for treatment with Palforzia given the lack of recommendation from the provider for the patient to receive oral immunotherapy. Therefore, the requested Palforzia 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 certification 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: The patient has requested authorization and coverage for rhinoplasty with the approved septoplasty. The records provided for review document that this patient has a symptomatic deviated nasal septum as a result of trauma, and correction of the deviated nasal septum has been authorized. In addition, the patient has a bump on his nose that is secondary to the same trauma. The records do not document any deviation of the nasal bones or breathing obstruction medically attributable to the bump on the nose. Thus, correction of the nasal bump would not be to improve a functional deficit. Spataro and Most noted that, physical examination findings are subjective and prone to bias. Although observer assessments are found to be sensitive for identifying anatomic deformities, they have low specificity in relation to subjective measures, meaning that clinicians may identify deformities that are not clinically significant. Karaogullarindan and colleagues stated that, significant septal deviation is nearly always a component of the deviated nose and that the degree of dorsal deviation correlates highly with patient-reported nasal obstruction. Based on the available documentation and medical literature, the requested rhinoplasty with the approved septoplasty is not medically necessary to treat the patients medical condition.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; (2) to create a normal appearance, to the extent possible. Based on the medical information received for review, the patients nasal deformity constitutes an abnormal structure of the body caused by trauma. Correction of the bump will not improve function based on the available documentation. However, the records support that the requested rhinoplasty with the approved septoplasty would create a more than minimal improvement in the patients appearance. Therefore, the requested rhinoplasty with the approved septoplasty is reconstructive in nature, and thus medically necessary, for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary and reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in plastic 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.