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

Findings:  The physician reviewer found that An enrollee has requested authorization and coverage for the medication Enbrel Sureclick 50mg/ml.According to the 2021 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis, the addition of a biologic DMARD, such as Enbrel, is recommended over triple therapy (i.e., addition of sulfasalazine and hydroxychloroquine) for patients taking maximally tolerated doses of methotrexate who still have uncontrolled rheumatoid arthritis with active disease symptoms.In this case, the patient has been on methotrexate since May 2015 and has required the use of additional DMARDs, Plaquenil and sulfasalazine, but has continued to have uncontrolled rheumatoid arthritis disease symptoms. As noted above, American College of Rheumatology guidelines recommend the addition of a biologic DMARD, such as Enbrel, for patients who have uncontrolled rheumatoid arthritis despite having optimized use of methotrexate. The guidelines recommend the addition of biologic DMARD therapy with a drug such as Enbrel rather than the addition of other conventional DMARDs such as Plaquenil or sulfasalazine. Accordingly, the requested medication, Enbrel Sureclick 50mg/ml, is medically necessary for this patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for this patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Findings:  The physician reviewer found that The patient has requested authorization and coverage for Calquence (acalabrutinib) 100 mg capsules. The records provided for review document that this patients condition has been stable on ibrutinib, but with reported side effects including nausea, poor appetite, and fatigue. Although the patient reports side effects, the patient has not reached the lowest dose reduction for ibrutinib, which is 140 mg daily. Akhtar and colleagues evaluated 70 patients with CLL treated with dose reductions of ibrutinib to improve drug tolerance. The authors found no statistical difference in overall response rate (ORR), clinical benefit rate (CBR), median progression-free survival, and overall survival (OS) between the dose-reduced and standard-dose groups (SDGs). In addition, the National Comprehensive Cancer Network (NCCN) does not recommend treatment with Calquence for management of this patients CLL. In this clinical setting, switching to Calquence is not consistent with current guidelines and peer-reviewed medical literature. For these reasons, the requested Calquence (acalabrutinib) 100 mg capsules are 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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for implantable peripheral nerve stimulation (PNS) device . In this case, the patient has chronic low back pain thought to be related to cluneal nerve entrapment based on positive response to two diagnostic injections. The provider has recommended peripheral nerve stimulation (PNS) of the cluneal nerve. Currently, there is insufficient medical evidence to support the efficacy of the requested PNS device in the medical literature with the bulk of the studies in the form of small case reports or case series. Researchers performed a review of cluneal nerve related pain syndromes and evaluated the various treatment options for this condition. The authors concluded that, While high-level evidence supporting PNS for clunealgias does not exist, several cases of successful pain relief post-implantation have been reported. Researches noted that two PNS techniques are showing promising results in clinical trials. However, there is a paucity of prospective randomized controlled trials reporting improved patient health outcomes with PNS in lieu of standard therapies. Based on the medical records for review and the current evidence-based medical literature, the requested implantable PNS device 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 implantable PNS device  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 device 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 anesthesiology with subspecialty certification in pain medicine and is actively practicing. Physician reviewer 2 is board certified in anesthesiology with subspecialty certification in pain medicine and is actively practicing. Physician reviewer 3 is board certified in anesthesiology with subspecialty certification in pain medicine 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for left first metatarsophalangeal joint interposition arthroplasty with Cartiva implant. Findings:  The physician reviewer found that The Cartiva implant is a novel polyvinyl alcohol (PVA) hydrogel implant with recent Food and Drug Administration (FDA) approval. Anderson and colleagues have noted that while early and midterm results comparing the PVA hydrogel implant to arthrodesis are encouraging, long-term studies are lacking. Emmons and colleagues have noted that a prospective, randomized, noninferiority trial was conducted to assess the efficacy of polyvinyl alcohol hydrogel implant in the setting of a side-by-side comparison with arthrodesis. They stated that a subset of the hydrogel implant group has now reached minimum 5-year follow-up, and the implant has demonstrated high rates of survival (96.3%) at midterm. They state, nevertheless, that whether these success rates will be reproduced in studies born from third-party investigators is unknown. Therefore, the hydrogel implant has moderate early results with a significant emphasis being placed on the lack of high-quality studies comparing it to the gold standard, which is noted to be arthrodesis. Thus, the left first metatarsophalangeal joint interposition arthroplasty with Cartiva implant in issue was not likely to have been more beneficial than any other available standard treatments for the patients medical condition.Findings: Three out of three physician reviewers found that the services at issue were not likely to have been more beneficial than any other available standard treatments for the patients medical condition.Final Result: The reviewers determined that the services at issue were not likely to be more beneficial than any other available standard treatments for the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in orthopaedic surgery and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and are 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 omalizumab (Xolair) 300 mg (60 units) subcutaneous injection every four weeks. Findings:  The physician reviewer found that Kaminsky and colleagues report that the treatment options for patients with idiopathic anaphylaxis who fail to respond to antihistamines and mast cell stabilizers are currently limited. The authors further note that treatment with omalizumab may be an effective option for these patients. In this case, the records note a diagnosis of idiopathic anaphylaxis and multiple episodes of anaphylaxis that cannot be anticipated. Given that conservative measures and treatments have not helped prevent attacks, the requested medication is medically indicated. Therefore, omalizumab (Xolair) 300 mg (60 units) subcutaneous injection every four weeks 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for proton beam radiation therapy and image guided radiation therapy. Findings: The records document that this patient has a history of clinically localized high risk prostate cancer. Current data in the peer-reviewed medical literature and clinical guidelines do not support treatment with proton beam radiation therapy for the treatment of this patients prostate adenocarcinoma. Proton beam radiation therapy has not been demonstrated to yield superior clinical outcomes as compared to intensity modulated radiation therapy (IMRT), with or without a brachytherapy boost, or radical prostatectomy. Moreover, there have been some prospective outcomes reported which have reported an excessive risk for gastrointestinal toxicity associated with proton beam radiotherapy. All told, the requested proton beam radiation therapy and image guided radiation therapy are 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 radiation oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for hyaluronic acid injections at 2 units per dose, one dose per week for three doses. 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 options are limited. The patient has been treated with and failed medications, injections of Depo Medrol, Toradol, and local anesthetics, as well as physical therapy and activity modification. Her pain is chronic, disabling, and sometimes severe. However, there is no indication for surgery. For these reasons, the requested hyaluronic acid injections at 2 units per dose, one dose per week for three doses are 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bilateral peripheral nerve stimulation (PNS) system (StimRouter). Findings:  The physician reviewer found that  systematic review performed by Deer and colleagues reported level II moderate evidence supporting the safety and efficacy of peripheral nerve stimulation (PNS) for the treatment of neuropathic pain of the shoulder. Common nerves that were targeted included the suprascapular nerve. In this case, the patient has neuropathic pain as a complication of foot and ankle surgery and spinal cord injury. Previous trials of standard of care treatments including medication management with neuromodulator agents, Botox, and physical therapy have been ineffective in improvement pain relief and improving quality of life and functionality. The patient has undergone tibial nerve blocks with effective short-term relief of his foot pain. Currently, the most recent reviews of PNS have shown level II evidence for efficacy in treating neuropathic pain in the lower extremities, as in this patients clinical setting. Based on these findings, the requested bilateral PNS system (StimRouter) is 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 bilateral PNS system (StimRouter) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested device is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in anesthesiology with subspecialty certification in pain medicine and is actively practicing. Physician reviewer 2 is board certified in anesthesiology with subspecialty certification in pain medicine and is actively practicing. Physician reviewer 3 is board certified in anesthesiology with subspecialty certification in pain medicine and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Lantus SoloStar insulin pen. Intensive insulin therapy resulting in good glycemic control has been shown to prevent and reduce the progression of diabetes-related complications in patients with type 1 diabetes (Lind, et al.). Currently, intensive glycemic control is generally achieved through multiple daily insulin injections or continuous subcutaneous insulin infusions through an insulin pump. Insulin is available in vials as well as prefilled pens. Studies have shown that the insulin pen can be significantly easier to use and less painful than the conventional vial and syringe (Ramadan, et al.). Compared with the vial and syringe method, insulin pens are more accurate, associated with greater adherence, and preferred by patients because of their convenience and ease of use (Cuddihy, et al.). This patient has reportedly successfully managed his diabetes with insulin pens in the past and he states that the insulin pen method was substantially more effective than using a vial and syringe. The patients provider supports the return to use of an insulin pen for this patient. For these reasons, the requested Lantus SoloStar insulin pen is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication dosage form 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 certification in endocrinology, diabetes, and metabolism 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 a series of Euflexxa injections to the left knee. Findings:  The physician reviewer found that medical literature pertaining to viscosupplemention reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. As such, the Academy does not currently support viscosupplementation as standard treatment for osteoarthritis of the knees. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, there is a history of failed arthroscopic surgery, ice, rest, corticosteroid injections, and the patient is not a candidate for total knee arthroplasty because of age and the absence of severe arthritis necessary for such a procedure. Under these circumstances, viscosupplementation is necessary for pain relief. Accordingly, the requested series of Euflexxa injections to the left knee is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary to treat 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 patient has requested reimbursement for the bilateral total capsulectomy and breast implant removal. Cohen Tervaert and colleagues state, Autoimmune/inflammatory syndrome by adjuvants (ASIA), allergies, autoimmune diseases, immune deficiencies and lymphomas occur in patients with silicone breast implants. Findings:  The physician reviewer found that the is a need for adequately adjusted epidemiological studies to ascertain the frequency of these diseases. Balk and colleagues conclude, The evidence remains inconclusive about any association between silicone gel implants and long-term health outcomes. Chao and colleagues report, Breast implant surgery is one of the most commonly performed procedures in the field of plastic surgery. While silicone implants are now routinely used in breast surgery, they have previously been the subject of controversy. This was particularly true in the U.S., where there was a moratorium on their use from 1992 to 2006. Following subsequent scientific validation of their safety, silicone implants have re-gained widespread acceptance for clinical use. Overall, silicone breast implants are associated with a high degree of patient satisfaction and low rates of complications. Further independent research is necessary to better establish long-term outcomes. In this case, the patient reports generalized complaints in the setting of silicone gel implants. However, given that the association of the patients complaints with the presence of silicone gel implants is speculative and cannot be confirmed, the service at issue was not medically indicated. Therefore, bilateral total capsulectomy and breast implant removal were not medically necessary for the treatment of this patient.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; or (2) to create a normal appearance, to the extent possible. In this case, the presence of a cosmetic implant, in the absence of adjacent native tissue structural pathology, does not constitute an abnormal structure of the body. Accordingly, bilateral total capsulectomy and breast implant removal were not reconstructive in nature for the 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 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.