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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Synvisc One injections. Medical Literature recommends hyaluronan acid for appropriate knee osteoarthritis patients, based on a large network meta-analysis (Trojian, et al.). This patient presents with persistent left knee pain with associated swelling, cracking and popping. The provider has documented functional limitations and clinical examination findings consistent with imaging evidence of left knee degenerative joint disease, relatively severe in the medial and patellofemoral joint. The patient has failed to achieve adequate improvement in pain and function with conservative treatment. Current evidence-based medical guidelines  hyaluronic acid injections in the knees for patients who have failed to respond adequately to conservative treatment and to potentially delay total knee replacement in patients with pain that interferes with functional activity. In this case, given the patients age, pain, and functional limitations, failure of comprehensive conservative treatment and potential delay of total knee arthroplasty, the use of hyaluronic acid injections is appropriate. Therefore, the requested Synvisc One injections 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for tramadol HCL. According to research, the use of a weak opioid in combination with an NSAID for pain control is indicated for mild to moderate pain and represents only the second step in the four-step ladder. Researchers have stated that medical necessity for chronic opioid therapy may be established on average moderate to severe pain (equal to 4, on a scale of 0 to 10) and/or disability. With regard to determining opioid dosage, researchers consider up to 40 morphine milligram equivalent (MME) as a low dose, from 41 to 90 MME as a moderate dose, and greater than 91 MME as a high dose. Medical literature states that clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety. Furthermore, medical literature suggests that if opioids are used, they should be combined with non-pharmacologic therapy and non-opioid pharmacologic therapy, as appropriate.In this case, the patient has verified evidence of multiple painful conditions that cause disability related to limited finger and elbow mobility. She has documented end stage osteoarthritis affecting the joints in her hand and elbows. She also has nerve conduction findings of severe nerve entrapment of the median and ulnar nerves. She also complains of elbow pain related to osteoarthritis of the elbows, which is associated with reduced extension of her right elbow. The patients provider notes state that she has tried and failed several conservative therapies including NSAIDs, physical therapy, splinting, and joint injections. The patient has signs and symptoms consistent with chronic pain due to longstanding severe osteoarthritis and nerve entrapment syndromes. Submitted documentation indicates that in addition to turmeric and Celebrex, the patient uses tramadol. In this case, the patient is well within the range consistent with low dose opioid therapy for a chronic non-cancer pain-related condition. The patient has not displayed signs of aberrant opioid use behavior, and she has tried and continues to pursue other treatment modalities, including surgical treatments. The patients records reflect that she is using the tramadol to allow her to perform activities of daily living. Under these circumstances, the requested tramadol HCL is medically necessary for treatment of the patients medical condition.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 anesthesiology, with subspecialty certification in pain management. The reviewer is an expert in the treatment of the patients 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:  The enrollee requests authorization and coverage for the prostatic urethral lift implant/UroLift surgery. He has a history of nocturia and erectile dysfunction. While hospitalized for an upper gastrointestinal bleed, he developed acute urinary retention and had an indwelling catheter placed.Findings: the physician reviewer found that  the catheter was removed and failed voiding trials, despite taking two Flomax capsules per day. A cystoscopy revealed evidence of urethral strictures, and an enlarged, inflamed prostate.  He was diagnosed with benign prostatic hypertrophy (BPH) with urinary retention.  He now requires a catheter to empty his bladder that has to be changed every 30 days.  The physician discussed the risks and benefits of transurethral resection of the prostate (TURP) versus UroLift surgery. The enrollee wants to have the UroLift procedure because it is a minimally invasive procedure with less complications than standard TURP.  UroLift was approved to treat benign prostatic hypertrophy (BPH) symptoms, with no evidence of an enlarged median lobe and overall prostate size of <80 grams.  The UroLift indications now include males as young as 45-years-old, and a median lobe was now acceptable for treatment with UroLift.  Guidelines mention UroLift as an acceptable treatment option for lower urinary tract symptoms secondary to BPH in men who are intolerant of medical therapy or have a desire to preserve sexual function/ejaculation. Transurethral resection of the prostate (TURP) will often result in lifelong retrograde ejaculation due to resection of the bladder neck. Medical studies have shown the voiding improvement after UroLift can be sustained for up to five years. Although UroLift and TURP have not been studied in a head-to-head comparison, UroLift is an outpatient procedure, is less likely to result in postoperative bleeding than TURP, and has a greater likelihood of preserving sexual function/ejaculation.  Final Result: Two of the three reviewers determined that the requested services are likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in urology and are actively practicing.  All three 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: A patient has requested authorization and coverage for bilateral breast revision reduction surgery. Current medical evidence does not support the requested services in this clinical setting. This patient complains of back pain and neck strain. There is no report of chronic breast pain due to weight of the breasts or intertrigo that is unresponsive to medical management. While the patient complains of neck strain, there is no documentation of upper back, neck, or shoulder pain. There is also no report of thoracic kyphosis, upper extremity paresthesia, headache, or congenital breast deformity. Shoulder grooving is not reported on physical examination and is not visible in photos received for review. Under these circumstances, the requested bilateral breast revision reduction surgery is not medically necessary for treatment of the patients medical condition. Pursuant to California Health & Safety Code  1367.63, every health care service plan contract must cover reconstructive surgery, which is 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 either improve function or to create a normal appearance, to the extent possible. In this case, the requested services do not address an abnormal structure of the body, and the appearance of the patient is normal. There is no documented loss of function. Furthermore, residual breast enlargement that follows breast reduction surgery is not a result of a congenital defect, a developmental abnormality, trauma, infection, tumors or disease. Accordingly, coverage for the requested bilateral breast revision reduction surgery in this case is not required by California Health & Safety Code  1367.63.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. The reviewer also determined that the requested services are not reconstructive surgery, as that term is defined by California Health & Safety Code  1367.63. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in plastic surgery. The reviewer is an expert in the treatment of the patients 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 hyaluronan injections to the left knee. Findings:  The physician reviewer found that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.An exhaustive review of the current medical literature pertaining to the viscosupplementation reveals mixed results. 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 medical evidence does not support viscosupplementation as standard treatment for osteoarthritis of the knees. 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 enrollee significantly benefited from prior injections, with symptom improvement for 11 months. The enrollee's options are limited, with the alternative being a total knee arthroplasty. There is sufficient support for the requested services in this clinical setting. Therefore, hyaluronan injections to the left knee are medically necessary for the treatment of this enrollee. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the enrollees 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 a bilateral lumbar medial branch block procedure. The patient has low back pain without radiation into the lower extremities. An MRI revealed disc bulges at L3-4 and L4-5 and mild bilateral facet arthrosis from L3-4 to L5-S1. The records suggest the bilateral lumbar medial branch block is for therapeutic purposes. A study found that the prevalence of high quality studies regarding the use of therapeutic medial branch blocks is limited. The best evidence for the use of medial branch blocks is for diagnostic purposes leading to a radiofrequency ablation procedure. Another study concludes that, facet blocks are not therapeutic. The records do not support that the injections are for diagnostic purposes, to help determine if the patient is a candidate for radiofrequency ablation, as supported in the medical literature. Therefore, the requested procedure 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Epidiolex. Findings:  The physician reviewer found that the current medical evidence supports the requested medication in this clinical setting. FIRES is a rare childhood epilepsy syndrome that is difficult to treat. This patients clinical history was published in a case series by Gofshteyn and colleagues. The case series included seven children with FIRES who were treated with cannabidiol. This patient was one of six children in the series whose seizures improved in frequency and duration. The medical literature noted cannabidiol (CBD) is one of the cannabinoids with non-psychotropic action, extracted from Cannabis sativa. CBD is a terpenophenol, and it has received a great scientific interest thanks to its medical applications. This compound showed efficacy as anti-seizure, antipsychotic, neuroprotective, antidepressant and anxiolytic. Epidiolex is a pharmaceutical formulation of highly purified CBD in oral solution. It has been demonstrated to be an effective long-term treatment option in Lennox Gastaut syndrome and Dravet syndrome, two forms of intractable generalized epilepsy syndromes in children, and is approved by the U.S. Food and Drug Administration (FDA) for those conditions. The medical literature noted open-label studies with 100mg/ml CBD have provided additional evidence of its efficacy along with an adequate safety profile (including certain drug interactions) in children and young adults with a spectrum of treatment resistant epilepsies. Therefore, Epidiolex 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 with special qualification in child 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 enrollee has requested authorization and coverage for Dupixent injections. Atopic dermatitis is an inflammatory skin disease characterized by immune activation, marked epidermal hyperplasia, and defective barrier function, reflecting underlying alterations in keratinocyte differentiation. The disease may be associated with significant morbidity, particularly when complicated by secondary infection. Frequent disruption of sleep is common, and emotional stress associated with the illness can have a significant impact on quality of life for patients and families. Treatment of atopic dermatitis usually starts with topical agents, such as corticosteroids, as well as phototherapy. Skin inflammation in atopic dermatitis results from inherited and acquired insults to the skin barrier, and agents that normalize the skin barrier reduce the dependence on topical steroids. Tacrolimus ointment and pimecrolimus cream have been demonstrated to be safe and effective in the treatment of patients with atopic dermatitis. Dupixent has been demonstrated to significantly reduce the clinical manifestations of moderate to severe atopic dermatitis. It also significantly reduces the pruritus of moderate to severe atopic dermatitis, thus improving quality of life. Dupixent had been approved for the treatment of moderate to severe atopic dermatitis. The Health Plans requirement for trial and failure of systemic immunosuppressors should be waived for this patient due to her comorbidity of severe asthma. Therefore, Dupixent injections are 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for partial hospitalization program (PHP) level of care services provided from 3/12/19 through 3/15/19 and 3/26/19 through 4/18/19 and a 90-day PHP level of care program. The American Psychiatric Association (APA) recommends a higher level of care than outpatient for patients who do not meet the clinical criteria for hospitalization but whose lives and social interactions have come to focus predominantly on substance use and lack sufficient social and vocational skills and drug-free social supports to maintain abstinence in an outpatient setting. The APA supports PHP level of care for patients who require structure, are cooperative and are partially motivated, but remain preoccupied with intrusive repetitive thoughts more than three hours per day. This patients records support a diagnosis of bulimia nervosa, alcohol use disorder, dysthymia, anxiety, and OCD. The patient was unable to maintain his sobriety in the outpatient setting prior to admission to PHP level of care. His lack of motivation post early discharge, lack of structure due to not working, and isolation supported an indication for PHP services. A lower level of care was not available with the provider with whom he had established rapport. Thus, continued PHP was appropriate. Given this patients comorbid substance use, eating and mood disorders, his relapse risks and risk of harm to self, PHP level of care services provided and a 90-day PHP level of care program, were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were and 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient is an enrollee who was diagnosed with alopecia areata (AA). The records noted that this condition affected greater than 50% of her scalp, and the patient had failed treatment with topical corticosteroids, intralesional Kenalog, and systemic corticosteroids. The documentation noted that patient had been treated with Xeljanz for two months, with near complete hair regrowth. A single patch of hair loss was noted to remain on her mid frontal scalp, and her eyebrows were laterally thinned. The patient has requested authorization and coverage for Xeljanz. The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. At issue in this case is whether Xeljanz is medically necessary for treatment of the patients medical condition. AA is a chronic immunological disorder characterized by round or oval patches of non-scarring hair loss. Alopecia universalis is a form of AA which includes eyebrows, eyelashes and facial hair. Depending on the extent of involvement, AA can have a significant negative impact on quality of life. Topical immune therapies or immunosuppressive drugs are typically used with mixed success. Various therapies for the disease may have efficacy in different patients, making a universal treatment algorithm difficult to implement. Patients should be managed on an individual basis, with the final outcome based on the cosmetic regrowth of hair. Maintenance therapy is also important in patients that do achieve acceptable regrowth. Xeljanz (tofacitinib citrate) is an oral janus kinase (JAK) 1/3 inhibitor, which has been demonstrated to be effective for the treatment of AA. Medical literatures indicate systemically administered pharmacological inhibitors of JAK family protein tyrosine kinases prevented the development of AA, while topical administration promoted hair regrowth and reversed the established disease. In this case, the patient has failed treatment with topical corticosteroids, intralesional Kenalog, and systemic corticosteroids but showed near full hair regrowth after two months of treatment with Xeljanz. Medical evidence supports the requested medication in this case. Therefore, Xeljanz 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 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.