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 Doptelet (20 mg once daily). In a phase III randomized study, Jurczak and colleagues report that avatrombopag (brand name Doptelet) was well tolerated and efficacious for the treatment of chronic immune thrombocytopenia (ITP). In this case, the patient has a diagnosis of ITP and experienced significant rectal bleeding despite treatment with intravenous immunoglobulin (IVIG). In this clinical setting, given that the patients ITP is associated with significant bleeding symptoms, the requested medication is medically indicated. Therefore, Doptelet (20 mg once daily) 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 and 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for Erbitux (cetuximab) 800 mg infusions every 14 days. The records document that this patient presents with metastatic poorly differentiated squamous cell anal carcinoma status post 5FU with mitomycin, radiation therapy, carboplatin with paclitaxel, and an anti-CTLA and anti-PD2 monoclonal antibody. The provider reports that the patient demonstrated progression on these therapeutic regimens. Treatment with FOLFIRI with Erbitux has yielded a significant response with an interval decrease in the size of multiple hepatic masses compatible with improving hepatic metastatic disease. Erbitux is an anti-EGFR antibody that has been found to be beneficial in certain cancers. Per researchers, The combination of a platinum agent and a fluoropyrimidine is generally considered the standard first-line treatment. Other cytotoxic agents, especially docetaxel and paclitaxel, have shown activity in both the chemotherapy-naive and chemo-refractory setting and are currently being investigated in clinical trials. Researchers performed a retrospective analysis which included 13 patients with anal carcinoma. The patients were treated with Erbitux alone or in combination with chemotherapy. There were four responses, three of which were in the patients treated with Erbitux plus chemotherapy. There was one complete response to Erbitux alone. The median progression-free survival of the whole group was 4.4 months, and the median overall survival was 11.4 months. This is anecdotal evidence of possible Erbitux usefulness, especially when combined with chemotherapy. Therefore, Erbitux (cetuximab) 800 mg infusions every 14 days were not and are 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 Erbitux (cetuximab) 800 mg infusions every 14 days were not and are 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 medication at issue was not and is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer 1 is board certified in medical oncology with subspecialty certification in hematology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certification in medical oncology 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: An enrollee has requested authorization and coverage for a Daavlin Home Phototherapy system (HCPCS E0694 - UV multidirectional light therapy system in 6 foot cabinet).At issue is whether the requested Daavlin Home Phototherapy system (HCPCS E0694 - UV multidirectional light therapy system in 6 foot cabinet) is medically necessary to treat the patients condition for any of the following: to prevent disease, disability, and other health conditions or their progression; to prolong life; to promote physical and mental health and efficiency; to correct or ameliorate any physical or behavioral conditions.Vitiligo is an acquired cutaneous depigmentation disorder which causes loss of melanocytes in the skin and mucosa. Vitiligo is an autoimmune disease, and depigmentation can evolve throughout a patients life. Vitiligo has major effects on self-esteem and social life, and quality of life is highly impaired in patients with this disease. Topical treatments may be applied alone when small areas are involved or when other treatment modalities are not readily available. Phototherapy combined with topical treatment is preferred when less than five to ten percent of the BSA is affected or when focal areas are unresponsive to topical treatments alone. Although several interventions are available to treat patients with vitiligo, no definite cure has yet been developed. Phototherapy, including psoralenultraviolet-A (PUVA) and NBUVB therapy, constitutes the principal treatment modality for generalized vitiligo.In this case, the patient requires treatment three times a week for an extended period. The home therapy unit for treatment of this disease would be necessary to prevent progression and to promote physical and mental health. Therefore, the requested Daavlin Home Phototherapy system (HCPCS E0694 - UV multidirectional light therapy system in 6 foot cabinet) is medically necessary to prevent disease, disability, and other health conditions or their progression.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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a LINX Reflux Management System (LINX device) with cruroplasty. Current medical literature has not established the safety and efficacy of the LINX procedure. Lipham and colleagues note in a multicenter, prospective, single-arm study of patients, that sphincter augmentation with the LINX Reflux Management System provided long-term clinical benefits without safety issues, as demonstrated by reduced esophageal acid exposure, improved quality of life related to gastroesophageal reflux disease (GERD), and cessation of dependence on proton-pump inhibitors (PPIs), with minimal side effects and no safety issues. However, Sheu and Rattner note that the long-term safety and efficacy of LINX  both alone and compared to current GERD therapies  remains to be determined. Bauer and colleagues note the possibility of adverse events, including erosion through the esophagus. The requested service has not been rigorously tested in randomized controlled trials against alternative therapies and therefore, it is not possible to not establish an individualized benefit in this case. Due to the lack of consensus among national and local health care providers, there are no set standard protocols regarding the terms and conditions for use. Therefore, a LINX Reflux Management System (LINX device) with cruroplasty is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested service is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology 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
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for an autologous mesenchymal stem cell regenerative medicine procedure. Researchers note that while there are Level I studies to support the use of platelet-rich plasma (PRP) and mesenchymal signaling cells (MSC) injections for discogenic pain, facet joint injections with PRP, epidural injections of autologous conditioned serum and epidural prolotherapy, and PRP and prolotherapy for sacroiliac joint pain, no studies to date have been published on the use of MSC injections administered via the sacroiliac joint. Researchers report that the available evidence regarding the use of MSCs has been assessed as Level III (on a scale of Level I through V). The authors did not note evidence supporting the use of MSCs in sacroiliac joint injections. In this case, the patient has sacroiliac joint-related pain and has undergone two joint injections with mixed results. Given the weak nature of the evidence in current medical literature supporting the use of MSC injections, and the lack of studies evaluating MSC injections for sacroiliac joint related pain, the requested service is not medically indicated. Therefore, an autologous mesenchymal stem cell regenerative medicine procedure is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty certification in pain 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: An enrollee has requested authorization and coverage for Avar LS.According to the most recent published guidelines of care from the American Academy of Dermatology, there is only limited evidence to support recommendations for sulfur and sodium sulfacetamide in the treatment of acne. There is a lack of support in the peer-reviewed literature demonstrating the efficacy of the requested medication in this clinical setting. Although there is some evidence to suggest the efficacy of sodium sulfacetamide, this is generally not peer-reviewed or well-supported. Additionally, Avar LS may be considered only a tertiary type of treatment. Medical literatures do not recommend sodium sulfacetamide or sulfur for the treatment of acne. In this case, the patient has been diagnosed with acne vulgaris. The medical evidence does not support the requested medication in this patients case. Therefore, the requested Avar LS is not medically necessary for the 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 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: An enrollee has requested authorization and coverage for Vumerity. Findings:  The physician reviewer found that Multiple sclerosis is a progressive immune disease affecting the central nervous system (CNS), causing neurological dysfunction. Multifocal inflammation of the CNS characterizes the disease and causes impaired nerve conduction. Multiple sclerosis is not a curable pathology; however, there are several medications that are approved by the U.S. Food and Drug Administration (FDA) and indicated for management. Vumerity has been established as safe, effective, and is consistent with generally accepted professional standards. In this case, the patient has been diagnosed with multiple sclerosis. The patient is taking several medications to manage her symptoms. There is sufficient support for the requested medication in this clinical setting. Therefore, Vumerity is medically necessary for the 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 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 parent of an enrollee has requested authorization and coverage for occupational therapy services. Findings:  The physician reviewer found that a set of guidelines on the management of children with autism spectrum disorder published by the American Academy of Pediatrics, Hyman and colleagues note that occupational therapy services may be indicated to promote fine motor and adaptive skills, including self-care, toy use, and handwriting. According to Bilaver and colleagues, almost two-thirds of preschool-aged children with ASD are reported to receive occupational therapy services. Many parents of children with autism spectrum disorder have described significant problems due to the coronavirus pandemic. Children with autism spectrum disorder frequently have difficulty attending to telehealth therapy. Goldberg notes that many children with autism spectrum disorder have lost previously acquired skills during the coronavirus pandemic. Manning and colleagues describe stress around therapeutic service disruption in families of children with autism spectrum disorder due to the coronavirus pandemic. In this case, the patient has autism spectrum disorder, and still requires verbal prompts to complete activities of daily living. The patient has had documented regression during the pandemic, during which time he has not been receiving therapy services in person. He has had an increase in self-stimulatory hand stereotypies, which are interfering with his ability to have appropriate adaptive function at home. Therefore, occupational therapy services are medically necessary to correct or ameliorate physical or behavioral conditions.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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for applied behavior analysis (ABA) therapy. Sakaluk and colleagues conducted a meta-analysis on the effectiveness of the most commonly used treatment modalities in treating a variety of psychological issues. Per the authors, cognitive behavior therapy (CBT) has strong support in the management of anxiety and depression. However, there is a lack of documented support for ABA for patients with adjustment disorder, anxiety, or depression. In addition, the request for ABA is not based on a thorough assessment of need and a treatment plan detailing the specific deficits to be addressed. Based on the Council of Autism Service Providers (CASP) and the ABA Coding Coalition, the required components of a treatment authorization include behavior analytic assessment and a treatment plan detailing specific goals to be targeted during treatment. This patients records lack documentation of elements to support ABA therapy. Moreover, the requested ABA therapy fails to meet the medical necessity criteria outlined by Papatola and Lustig. According to Papatola and Lustig, medically necessary ABA services are (a) required to meet the essential health needs of the patient; (b) consistent with the diagnosis of the condition for which they are required; (c) consistent in type, frequency, and duration of treatment with scientifically based guidelines as determined by medical research; (d) required for purposes other than the convenience of the provider or the comfort of the patient; and (e) rendered in the least intensive setting that is appropriate for the delivery of health care. This patient does not meet criteria (a), (b) and (c). The records do not support that the requested ABA services are medically necessary to meet the essential health needs of the patient, ABA services are not consistent with the diagnoses for which they are being requested, and there is a lack of guidelines supporting ABA for the treatment of adjustment disorder, anxiety, or depression. For these reasons, the requested ABA therapy is not medically necessary for treatment of the patients mental health or substance use disorder as defined in Health and Safety Code section 1374.72(a)(3)(A).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 licensed B.C.B.A, board certified in psychology, 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 weekly individual psychotherapy. Findings:  The physician reviewer found that the records document that the patient continues to endorse significant symptoms of anxiety and depression despite numerous medication trials and seeing numerous providers, including psychiatrists, therapists, pharmacists, and group clinicians. Her symptoms of depression and anxiety and overall functioning have worsened. The records note that the patient seeks out individual therapy and improved with individual contact. Given the patients symptoms of anxiety and depression, along with possible additional diagnosis of personality disorder, weekly individual psychotherapy is medically indicated. In this patients case, weekly individual psychotherapy is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested services are clinically appropriate in terms of type, frequency, extent, site, and duration. The requested services are not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Therefore, weekly individual psychotherapy is medically necessary for the 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for peroral endoscopic myotomy (POEM) procedure. This patient presents with significant ongoing symptoms, including dysphagia and regurgitation, which have not responded durably to esophageal dilation. A barium swallow study confirmed the inability for the barium tablet to pass through the patients esophagogastric junction. The patients provider has recommended treatment with the POEM procedure. As noted in the medical literature, POEM is a minimally invasive endoscopic procedure that allows for the treatment of esophageal disorders without chest surgery (Chandan, et al.). POEM has been demonstrated to be safe and effective in multiple studies for patients with jackhammer esophagus and other related spastic esophageal disorders (Khashab, et al.; Bechara, et al.; Kandulski, et al.; Feng, et al.). Given this support, the requested POEM is supported as medically necessary for the 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 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.