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

The patient has requested authorization and coverage for Victoza 1.2 mg subcutaneously every day. Victoza is glucagon-like peptide-1 (GLP-1), a multifaceted hormone with broad pharmacological potential. Researchers noted,  Among the numerous metabolic effects of GLP-1 are the glucose-dependent stimulation of insulin secretion, decrease of gastric emptying, inhibition of food intake, increase of natriuresis and diuresis, and modulation of rodent -cell proliferation. While GLP-1 receptor agonists (GLP-1RAs) have already proven to be an efficient treatment option for type 2 diabetes, researchers conducted a meta-analysis which supported the use of GLP-1RAs in treating patients with type 1 diabetes. In this case, the patient has type 1 diabetes and has responded well to Victoza in the past. Therefore, Victoza 1.2 mg subcutaneously every day is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for transcatheter aortic valve replacement. Researchers note a central component for transcatheter aortic valve replacement (TAVR) consideration is the underlying risk for surgical aortic valve replacement, based on the STS score. Researchers reported that while TAVR is an alternative to surgery in patients with severe aortic stenosis who are at increased risk for death from surgery, TAVR was noninferior to surgery even for patients with low surgical risk. In this case, the patient has severe aortic stenosis, increasing symptoms of dyspnea on exertion, and several comorbidities, including moderately severe pulmonary hypertension, asthma, and hepatic cirrhosis, with an elevated STS surgical mortality risk of 3.45%. She was evaluated by a comprehensive heart team, including a cardiac surgeon and a cardiologist, and the team recommended TAVR based on these factors. Therefore, transcatheter aortic valve replacement 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 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: An enrollee has requested authorization and coverage for Humira Citrate-Free 40 mg/0.4 ml pen.Humira is effective for the treatment of pouchitis with characteristics of Crohn's disease, and is recommended by guidelines for the treatment of Crohn's disease. The pain associated with citrate in Humira and other medications is associated with negative impact of adherence in patients with inflammatory bowel disease, and the citrate-free formulation of Humira is associated with significantly less injection-site pain. In this case, the patient has a history of ulcerative colitis and is status-post pouch. The patient has a current diagnosis of Crohns disease and has symptoms of active pouchitis. The provider has recommended aggressive treatment that will include Humira, in order to avoid progression of illness. Under these circumstances, the requested Humira Citrate-Free 40 mg/0.4 ml pen is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary to treat the patient's 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: Overturned Decision of Health Plan

The patient has requested authorization and coverage for galcanezumab-gnlm 120 mg/ml injection (Emgality). Researcher describes galcanezumab as a humanized monoclonal antibody against the calcitonin gene-related peptide (CGRP) ligand with significant benefit in the preventive treatment of migraine in adults. In the EVOLVE-1 (Evaluation of LY2951742 in the Prevention of Episodic Migraine 1) trial, researchers compared galcanezumab to placebo, and found that treatment with galcanezumab significantly reduced monthly migraine headache days compared with placebo. In this case, the patient has a history of migraines. She had tried multiple medications without improvement, and she has benefitted from the requested medication. Her provider supports the medical necessity of galcanezumab. Therefore, galcanezumab-gnlm 120 mg/ml injection (Emgality) is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has requested authorization and coverage for scar tissue removal surgery. The patient underwent cosmetic breast augmentation surgery years ago and developed an area of depressed scar that pulls on the underlying tissue when she raises her arm. She reports pain when this occurs. Kumar and Elavarasi stated, Pain is always subjective, and every individual use this word through their previous experience related to the injury. Attachment of a scar to the underlying tissues may result in discomfort. Based on the history of the presence of severe pain, scar tissue removal is medically necessary. 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. In this case, a depressed scar following breast augmentation surgery is not a result of a congenital defect, a developmental abnormality, trauma, infection, tumors or disease. It is not an abnormal structure of the body. The appearance of the patient is normal, and scar revision would result in only minimal improvement in appearance. Therefore, the requested scar tissue removal surgery is not reconstructive in nature for 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient has requested authorization and coverage for total hip arthroplasty. The American College of Rheumatology (ACR) recommends total joint arthroplasty for patients with hip osteoarthritis following failed medical therapy. The ACR therapy recommendations include exercise, weight loss when indicated, medication management, manual therapy, walking aids, and psychosocial interventions. This patient presents with complaints of significant low back pain radiating to the left lower extremity with signs and symptoms of neurogenic claudication, as well as bilateral hip pain. The patients standing tolerance is significantly limited by leg fatigue. Hip examination revealed slightly limited range of motion and positive left provocative test. There is imaging evidence of left hip cam type femoroacetabular impingement and a small tear of the right superior labrum. There is radiographic evidence of cam lesions and mild osteoarthritis. He has been recommended for lumbar decompressive surgery. There is significant evidence of lumbar mediated radicular pain, along with neurogenic claudication that limits functional mobility. There are mild clinical findings, with mild radiographic osteoarthrosis noted at the hips. Lumbar surgery has been recommended and is indicated prior to consideration of hip surgery. All told, the requested total hip arthroplasty 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 transcranial magnetic stimulation (TMS). The U.S. Food and Drug Administration (FDA) has approved the use of TMS for the treatment of major depression in patients who have not responded to previous trials of antidepressants. Researchers noted that current data support the safety and utility of repetitive TMS for patients with unipolar depression, less severe depressive episodes, treatment-resistant depression, non-psychotic depression. Similarly, researchers concluded that TMS has substantial evidence of efficacy and safety for treating the acute phase of depression in patients who are treatment resistant or intolerant. Based on the records provided for review, this patient has evidence of treatment resistant depression. Her provider documented failure of Prozac, Lexapro, Cymbalta, and Wellbutrin XL. Further, there is evidence of previous success with repetitive TMS. Given these findings, the requested TMS 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 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: Upheld Decision of Health Plan

The patient has requested authorization and coverage for 30 minutes of general anesthesia (CDT D9222 and D9223) for a surgical tooth extraction. Per the American Dental Association (ADA), moderate sedation is appropriate for patients with obesity, or American Society of Anaesthesiologists (ASA) scores of III or IV, especially when associated with airway-associated morbidities. The ADA noted that deep sedation or general anesthesia is supported for mentally or physically challenged patients. The American Academy of Pediatric Dentistry (AAPD) states that general anesthesia may be indicated for patients who cannot cooperate due to a lack of psychological or emotional maturity and/or mental, physical, or medical disability; patients for whom local anesthesia is ineffective because of acute infection, anatomic variations, or allergy; the extremely uncooperative, fearful, anxious, or uncommunicative child or adolescent; patients requiring significant surgical procedures; patients for whom the use of general anesthesia may protect the developing psyche and/or reduce medical risk; and patients requiring immediate, comprehensive oral/dental care. In this case, the patient requires surgical tooth extraction and bone grafting. She reports anxiety and fear related to the planned procedure. The records provided for review do not document an ASA classification score of III or IV, evidence of a difficult airway, or an AAPD indication to support general anesthesia for the surgical extraction and bone grafting. Moreover, the provider did not document that there were previous attempts to complete the planned dental procedures with mild or moderate sedation. Based on the medical records available for review and the current national guidelines, the requested 30 minutes of general anesthesia (CDT D9222 and D9223) for a surgical tooth extraction 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

The patient has requested authorization and coverage for Dupixent syringes 300 mg/2 mL. Atopic dermatitis is a complicated immunologic disorder that primarily involves TH2 helper cell dysfunction. Dupixent is a monoclonal antibody targeted therapy that significantly reduces disease and associated symptoms. As topical agents require application to affected areas, in widespread disease, systemic agents are indicated. Compared with conventional immunosuppressive agents, Dupixent has a favorable safety profile and may be used for long-term treatment of atopic dermatitis. This patient presents with atopic dermatitis on a substantial portion of his BSA. His symptoms have persisted despite treatment with corticosteroids. Dupixent is appropriate to treat this patients chronic atopic dermatitis in conjunction with topical agents and non-pharmacokinetic measures. Therefore, the requested Dupixent syringes 300 mg/2 mL are 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for laparoscopic hysterectomy, CPT 58571. For women who have completed childbearing and have significant symptoms, and a desire for a definitive end to symptomatology, definitive therapy with a hysterectomy is appropriate under the standards of care. In this case, the patients prolonged abnormal bleeding has had a significant impact on her quality of life. The provider has counseled the patient regarding all treatment options available, including less aggressive hormone therapy or ablation versus a more aggressive but definitive total hysterectomy. Given the patients age, diagnostic work-up, and poor tolerance of hormones, a laparoscopic assisted vaginal hysterectomy is medically indicated as the only definitive treatment that will treat her abnormal bleeding. Therefore, laparoscopic hysterectomy, CPT 58571 is medically necessary for the treatment of his 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for an office consultation with a dermatologist. Studies found that topical calcineurin inhibitors (TCIs), including tacrolimus and pimecrolimus, both as a monotherapy and in combination with phototherapy, should be encouraged in patients with vitiligo. However, reporters noted that because of its mechanism of action, a potential risk of adverse reaction in long-term use of topical tacrolimus included trichomegaly. This patient has vitiligo and has been using tacrolimus for approximately one year. Given the possible side effects of the currently prescribed medication, a consultation with a dermatologist is medically indicated. It is medically appropriate for this patient to receive an evaluation of her condition and confirmation that she is on the proper treatment for her condition. Therefore, an office consultation with a dermatologist 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 dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Nutropin AQ dispensed by a Board-Certified Pediatric Pharmacy Specialist. Based on the records provided for review, this patient presented for repeat visits with a height Z-score that is less than four standard deviations below the mean. Thus, he meets the current criteria for small for gestational age (SGA) with failed catch-up growth. However, there is a lack of data in the medical literature to support use of a pediatric pharmacist to determine the appropriate dose of recombinant growth hormone for this patient. The decision to start recombinant growth hormone and change the dose of growth hormone is made by a board certified pediatric endocrinologist based on the age, height and weight of the patient, growth over time and the results of laboratory testing including IGF-1 and IGFBP-3. All told, the requested Nutropin AQ dispensed by a Board-Certified Pediatric Pharmacy Specialist is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in pediatrics with subspecialty certification in pediatric endocrinology 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

The patient is a male who has been diagnosed with chronic urticaria, The treatment plan included hydroxyzine. The provider noted a punch biopsy performed in June revealed urticaria on the patients forearm. The provider noted that the patient had urticaria for longer than six weeks and was unresponsive to antihistamines. The patient was being treated with Allegra, twice a day, Pepcid AC, Singulair, and triamcinolone. The provider noted that there was no clinical evidence of lupus of thyroiditis. In a letter dated, the provider noted that the patient remained symptomatic despite treatment with Allegra, Singulair, protopic, and triamcinolone.  On the provider noted that the patients urticaria had improved following a Xolair injection provided in 2020. The patient has requested authorization and coverage for Xolair (omalizumab) 300 mg injections every four weeks. The Health Plan denied the request and reported that the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether Xolair (omalizumab) 300 mg injections every four weeks are medically necessary for the treatment of the patients medical condition. Beck and colleagues reported, Patients with chronic urticaria who visit a specialist have typically been treated with second-generation H1-antihistamines, the recommended first-line treatments. Kaplan reported, The use of antihistamines in high dosage (at least four times a day) is effective in close to half the patients with chronic spontaneous urticaria (CSU). Westby and colleagues noted, Guidelines suggest that first-line therapy includes second-generation non-impairing, non-sedating H1-antihistamines. If no response by two to four weeks, up-dosing with second-generation H1-antihistamines, up to fourfold increase, has been widely adopted as a safe and efficacious second-line therapy when treatment is inadequate with standard therapeutic dosages. In this case, the patient was treated with Allegra twice a day, but a dosage of four times per day is not documented. A second-generation antihistamine should be maximized, and an adequate trial performed before moving to the next step, which would be Xolair. The medical evidence does not support the requested medication in this clinical setting. Therefore, Xolair (omalizumab) 300 mg injections every four weeks 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patients parent has requested reimbursement and prospective authorization and coverage for Emflaza. In a study of 196 boys with DMD aged five to fifteen, researchers concluded that, After twelve weeks of treatment, prednisone and both doses of deflazacort improved muscle strength compared with placebo. Deflazacort was associated with less weight gain than prednisone. Researchers also found lower functional decline with deflazacort compared with prednisone in the treatment of boys with DMD. Researchers studied the outcomes of long-term prednisone and deflazacort in patients with DMD and reported that, Deflazacort was also associated with a lower risk of scoliosis and better ambulatory function, greater percent lean body mass, shorter stature and lower weight, after adjusting for age and steroid duration. Medical literature noted the potential danger of changing between corticosteroid classes in DMD cardiomyopathy. In this case, the patient was switched to Emflaza due to weight gain and has been stable on Emflaza. The medical literature shows that deflazacort, as compared to prednisone, is more effective at slowing disease progression and is associated with a lower risk of scoliosis, greater percentage lean body mass, and less weight gain. Taking the patient off Emflaza in favor of prednisone would put the him at risk for the development of acute myocarditis. Therefore, Emflaza was and is medically necessary for treatment of this patient.