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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Otezla (generic form apremilast) 30 mg tablets. The submitted documentation supports the medical necessity of the requested medication. Psoriasis has a high negative impact on the quality of life, especially in patients moderately or severely affected by the disease. The long-term use of traditional systemic therapies is frequently unacceptable because of renal, hepatic, pulmonary toxicity and limited efficacy. Traditional systemic therapies for psoriasis, including methotrexate and cyclosporine, have a well-documented array of toxicities, particularly end-organ toxicities. Over the past several years, the use of anti-tumor necrosis factor biologic therapies for the treatment of moderate to severe psoriasis has been a major clinical and research focus. Despite several difficulties with documenting risks, some systemic treatments for psoriasis have been linked with an increased risk of selected cancers. In addition, patients treated with anti-tumor necrosis factor drugs may develop adverse events such as infections, acute infusion and injection reactions, autoimmunity and cardiovascular effects. It has been well-documented that therapies of psoriasis with injectable biologics increase the risk for malignancy and infection, mandating prior testing for tuberculosis. Apremilast (brand name Otezla), an oral PDE4 inhibitor, provides a novel therapeutic option for the treatment of patients with moderate to severe plaque psoriasis. Its effects on cyclic adenosine monophosphateregulated intracellular signaling, gene expression, and subsequent protein levels allow apremilast to modulate the immune responses that cause the inflammation associated with psoriasis. In this case, the patient has severe plaque psoriasis affecting more than 20 percent of their BSA that requires systemic treatment. The anti-tumor necrosis factor drugs recommended by the Health Plan can increase the risk for infection and malignancy. The medical evidence supports Otezla in this clinical setting. Therefore, the requested Otezla tablets are 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 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 Xeljanz tablets. Findings:  The physician reviewer found that the submitted documentation supports that the requested medication is medically necessary. The use of Xeljanz for ulcerative colitis is well supported. Xeljanz has a different mechanism of action than anti-TNF therapies. In this case, the patient has failed alternatives, including the anti-tumor necrosis factor (TNF) medication Humira. The patient has started Xeljanz with good relief of symptoms. For this patient, the discontinuation of Xeljanz or a change to an alternate therapy may result in a disease flare or other complication. Under these circumstances, Xeljanz tablets are 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the preconceptional genetic testing (CPT codes 81200, 81209, 81242, 81251, 81255, 81256, 81257, 81260, 81290, 81330, and 81400). As noted by the American College of Obstetricians and Gynecologists (ACOG), some screening tests are routine and offered to all pregnant women, while others are generally only ordered when a genetic trait is suspected. According to the ACOG practice bulletins, screening for spinal muscular atrophy (SMA) and cystic fibrosis should be offered to all women who are considering pregnancy or are currently pregnant. In addition, fragile X carrier screening is recommended for women who are considering pregnancy or are currently pregnant and have a family history of fragile X related disorders or intellectual disability suggestive of fragile X syndrome. Screening for Tay-Sachs disease should be offered when considering pregnancy or during pregnancy if either member of a couple is of Ashkenazi Jewish, French-Canadian, or Cajun descent. In this instance, this patients records do not document any of these indications for specific testing. The standard of care includes testing for SMA and cystic fibrosis, not the entire Preparent Global Panel. Thus, preconceptional genetic testing (CPT codes 81200, 81209, 81242, 81251, 81255, 81256, 81257, 81260, 81290, 81330, and 81400) was not likely to be more beneficial for evaluation of this patients medical condition than any available standard testing. One reviewer found that preconceptional genetic testing (CPT codes 81200, 81209, 81242, 81251, 81255, 81256, 81257, 81260, 81290, 81330, and 81400) was likely to be more beneficial for evaluation of this patients medical condition than any available standard testing.Final Result: Two of the three reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications:  One reviewer is board certified in obstetrics and gynecology and is actively practicing. One Reviewer is board certified in obstetrics and gynecology and is actively practicing.  One Reviewer is board certified in obstetrics and gynecology and is 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the laboratory testing. According to the American College of Obstetricians and Gynecologists (ACOG), the diagnosis of rupture of membranes (ROM) is traditionally made based on patient history and clinical examination including a speculum evaluation of the vagina and cervix. Typically, the patient history, with its description of leakage of fluid, can help to confirm or rule out the diagnosis. This is coupled with a sterile speculum examination to provide direct visualization to evaluate for pooling, to evaluate the pH of any secretions, and to perform a microscopic examination for cervical ferning complete the examination. From a review of the medical records, this patient had a high risk course and was complaining of additional moisture and discharge. Several tests were performed including a sterile speculum examination, a swab, AmniSure testing, and a vaginal culture to evaluate for leakage of fluid. The documentation states that ferning that was performed and was negative. The description of the fluid, from the sterile speculum examination, as white and not clear, is not consistent with a diagnosis of pooling of amniotic fluid. There is no documentation of pH testing. Given the findings on sterile speculum examination, additional testing for ROM was not needed. All told, the laboratory testing was not likely to have been more beneficial for evaluation of this patients medical condition than any available testing. One reviewer found that the laboratory testing was likely to have been more beneficial for evaluation of this patients medical condition than any available testing.Final Result: Two of the three reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications:  One reviewer is board certified in obstetrics and gynecology and is actively practicing. One Reviewer is board certified in obstetrics and gynecology and is actively practicing.  One Reviewer is board certified in obstetrics and gynecology and is 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Doppler-guided transanal hemorrhoidal dearterialization surgery.Three physician reviewers found that although it is a promising treatment for hemorrhoids, Doppler-guided transanal hemorrhoidal dearterialization is not supported by the current medical literature or guidelines as superior to other first-line alternatives. This treatment has success rates comparable to hemorrhoidectomy and stapled hemorrhoidopexy. The current studies have shown that Doppler-guided transanal hemorrhoidal dearterialization is comparable to conventional surgical hemorrhoidectomy for advanced hemorrhoidal disease in efficacy and safety. Further studies are needed to establish that Doppler-guided transanal hemorrhoidal dearterialization is more effective than established methods for the treatment of hemorrhoids. Therefore, Doppler-guided transanal hemorrhoidal dearterialization surgery was not likely to have been superior over other treatment options. Final Result: The reviewers determined that the services at issue were 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 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 reimbursement for transcranial magnetic stimulation (TMS). The submitted documentation supports that the services at issue were medically necessary. The exact Number of TMS treatments needed for successful depression symptom resolution is not clearly defined in the evidence based literature. It does appear that certain patients need more than 30 treatments to come to successful resolution of their symptoms. The literature indicates that repeated rTMS applications have demonstrated a reproducible antidepressant effect in patients with refractory depression who initially showed a clinically significant benefit. The duration of effect varied across patients, but benefits were sustained for a mean of nearly 5 months. At this time, there are no hard and fast guidelines for the exact number of necessary TMS treatment sessions, and because many patients respond slightly or drastically different to TMS, the number of sessions often needs to be considered on a clinical basis instead of a numerical basis.In this case, the patient had previously received approximately 26 TMS treatments. The progress notes indicated that the patient made consistent progress during TMS treatment. Over the course of the additional treatment, she described mood improvement and indicated that overall daily function had improved dramatically, including an improved ability to perform activities on a daily basis that she was struggling with in the beginning stages of treatment.. The patient appeared to be tolerating treatment well, and the eventual sessions administered after the Health Plans denial of additional TMS sessions were more effective for her. Under these circumstances, the transcranial magnetic stimulation (TMS) services at issue were medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients condition. Therefore, the patient should be reimbursed for the services at issue, and 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 a 64-year-old male who presented to the podiatrist with a six-month history of right heel pain. Findings:  The physician reviewer found that after attempts with over-the-counter orthotics, it is standard of care to biomechanically correct the over-pronated gait with custom functional firm orthotics. The biomechanics of custom orthotics is very sound. They reduce over-pronation by keeping the foot in a neutral position. This alleviates pressure on the plantar fascia and plantar heel, resolving patients pain (Fong). It is well documented that this patient suffers from right heel pain. Diagnosis of plantar fasciitis and over pronated gait have been made. The patient has attempted OTC orthotics without resolution of pain. After careful review of the enclosed information, the requested custom orthotics are medically necessary to treat this patients plantar fasciitis. Therefore, the requested custom orthotics are medically necessary and the Health Plans decision should be overturned.Final Result: The reviewer determined that the requested devices 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 podiatry 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 reimbursement for Monitored Anesthesia Care (MAC). Findings:  The physician reviewer found that most lower endoscopy tests can be accomplished with no sedation, moderate sedation, or deep sedation; general anesthesia and active airway management are rarely needed. Propofol-based sedation has advantages in terms of satisfaction and recovery over other modalities, but moderate sedation using benzodiazepines and opiates work well for low-risk patients and procedures. The level of planned anesthesia determines who will be administering the sedation. Light or moderate sedation are usually administered by the gastroenterologist performing the procedure. Deep sedation and general anesthesia are administered by a nurse anesthetist or anesthesiologist. MAC is administered by an anesthesia professional who is in the room with the gastroenterologist and a nurse or technician. This is usually selected when there are concerns about the patients lungs, heart, or tolerance to midazolam or fentanyl. In this case, the patient has a past medical history of gastroesophageal reflux disease and hyperlipidemia. She has no evidence of significant cardiac or pulmonary comorbidity to substantiate the need for MAC during the colonoscopy. The American Society of Anesthesiologists (ASA) Score is a global score that assesses the physical status of patients before surgery. It is sometimes referred to as ASA-PS, because it is a measure of physical status. In scoring this patient, she is otherwise healthy, with only mild to moderate systemic medical conditions, and she is therefore classified as an ASA II patient. MAC is not medically indicated for ASA II patients. Accordingly, the Monitored Anesthesia Care (MAC) services at issue were not medically necessary for the patients medical condition.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 anesthesiology, with subspecialty 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 an electric wheelchair. The submitted documentation does not support that the requested electric wheelchair is medically necessary. A study finds in the setting of neurologically-based mobility impairments, more active means of mobility are generally preferable to less active means of mobility for the purposes of general health promotion.In this case, the submitted records indicate that the patient has cervical spinal stenosis with some motor impairments in his right upper and right lower limb. He also has chronic pain and has been on opioids chronically. As regards the patients function, the records do not provide either a sufficiently detailed functional history or detailed examination to establish that the patients impairments are significant enough to preclude the use of a cane, walker or manual wheelchair to accomplish the patient's mobility-related activities of daily living. The records indicate that the patient had undergone physical therapy for gait training and that he has been ambulating short distances with a cane outside of the therapy setting. Accordingly, an electric wheelchair is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested equipment 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 physical medicine and rehabilitation 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:An enrollee has requested reimbursement for Residential Treatment Center (RTC) services. Findings:  The physician reviewer found that in this case, the submitted documentation does not reflect that the patient had a psychiatric emergency medical condition during the period that he received RTC services. At the time of his admission to the RTC, the patient was diagnosed with cannabis use disorder and bipolar disorder, type I. The submitted records reflect that the patient denied any suicidal or homicidal ideation and did not have any auditory/visual hallucinations or psychosis during the period that he received RTC services. The patients drug screens were found to be negative on multiple occasions during this time period. He had been recently discharged from an inpatient stay where he was to follow up with his provider as an outpatient. At the time of admission to the RTC, the patient was evaluated by an intern and by an attending Doctor of Psychology, and it was determined that the patient was not in an immediate danger to himself or to others, and was not immediately unable to provide for or utilize food, shelter, or clothing due to his mental disorder. Under these circumstances, the Residential Treatment Center (RTC) services at issue did not constitute psychiatric emergency services as defined by California law.Final Result: The reviewer determined that the services at issue were not psychiatric emergency services as defined by California law. Therefore, the Health Plans denial should be upheld.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: An enrollee has requested authorization and coverage for Euflexxa viscosupplement injections. The current literature continues to support the use of viscosupplementation for osteoarthritis of the knees. There is good evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. Evidence from studies of repeat courses of intraarticular hyaluronic acid demonstrates an improvement in pain or function lasting up to 40 months, a reduction in use of concomitant analgesia by up to 50%, and suggests that there may be a delay in the need for total knee replacement of around 2 years. The reviewer found that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for knee osteoarthritis and that its use results in improvements in knee pain and function that can persist for up to 26 weeks. Intra-articular hyaluronic acid has a good safety profile, and its use should be considered in patients with knee osteoarthritis. There is sufficient support for the requested services in this clinical setting. Therefore, Euflexxa viscosupplement injections are medically necessary to treat 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.Findings:  The physician reviewer found that