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

Findings:  The physician reviewer found that The patient has requested authorization and coverage for Synvisc One injection to the left knee. 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 patient has been treated with conservative options including physical therapy, medications, including analgesics, anti-inflammatory medications, topicals, methotrexate, and bracing. The provider has recommended viscosupplementation with Synvisc One for the left knee. In this clinical setting, the requested Synvisc One injection to the left knee is medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for diabetes prevention program. Type 2 diabetes mellitus is a common chronic metabolic condition. Before receiving this diagnosis, patients typically experience a long period of prediabetes. There is adequate evidence that type 2 diabetes mellitus can often be prevented or delayed by means of lifestyle interventions, medications, or metabolic surgery (Shubrook, et al.). Clinical trials have reported that patient education can help improve clinical, lifestyle, and psychosocial outcomes. Coppola and colleagues noted that, The management of type 2 diabetes mellitus includes ability and empowerment of the patient to change lifestyle, maintain an adequate diet and physical activity, manage the disease, and follow a specific program of periodic medical checks and education sessions. The authors concluded that, To obtain these goals, therapeutic patient education (TPE) is now considered a crucial element not only in the treatment but also in the prevention of type 2 diabetes. However, this patients records do not include an indication for the requested diabetes prevention program. The provider noted that the patients glucose was 81 mg/dL six months prior, with a target reference range of 60-159 mg/dL. Therefore, the requested diabetes prevention program 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for left hip endoscopy with iliotibial band fasciotomy and bursectomy, abductor tendon repair (29863). The records document that this patient is being treated for rupture of tendon of hip abductor. The patients pain is located in the peri-trochanteric anterior lateral aspect of the left hip. The patients pain is exacerbated by activity. The patient has exquisitely tenderness to palpation over the abductors and proximal trochanteric region. The patients provider has recommended left hip endoscopy with iliotibial band fasciotomy and bursectomy, abductor tendon repair. However, there is a paucity of large-scale long-term peer-reviewed studies demonstrating that this is an effective and safe treatment for this patients pathology. Zhu and colleagues evaluated the available treatment options for patients with hip abductor tears. The authors found that, While surgery has been attempted over the last two decades, the outcomes are variable, and the lack of high-quality studies have limited the uptake of surgical repair. Chandrasekaran and colleagues concluded that open and endoscopic gluteal repairs have similar patient-reported outcome scores, pain scores, and improvement in abduction strength. On review of the available medical literature, there is a lack of support for the requested surgical intervention for management of this patients left hip pain. All told, the requested left hip endoscopy with iliotibial band fasciotomy and bursectomy, abductor tendon repair (29863) 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing. There is a lack of clinical studies in current medical literature demonstrating that advanced lipoprotein testing adds significant actionable information to what is already known from a basic fasting lipid panel, or that therapies to correct novel lipoprotein abnormalities, such as lipoprotein(a) and apolipoprotein (apo) B have any effect on cardiovascular outcomes such as myocardial infarction, stroke, or death. In this clinical setting, there is insufficient evidence to support the use of the service at issue, particularly given this patients low risk of atherosclerotic cardiovascular disease (ASCVD). Therefore, advanced lipoprotein testing was not likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the advanced lipoprotein testing at issue was not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was not likely to have been more beneficial for evaluation 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 internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. Physician reviewer 2 is board certified in internal medicine with sub-specialty certifications in cardiovascular disease and in adult congenital heart disease and is actively practicing. Physician reviewer 3 is board certified in internal medicine with sub-specialty certifications in interventional cardiology and in cardiovascular disease 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Factor V Leiden genetic testing. Thrombophilias are hereditary or acquired conditions which can increase the risk of venous or arterial thrombosis (Stevens, et al.). As the etiology of thrombosis is multifactorial, the presence of a thrombophilic defect is only one of many elements that determine a patients risk. Factors associated with an inherited thrombophilia include venous thrombotic event at a young age, a strong family history, venous thrombotic event in conjunction with weak provoking factors at a young age, recurrent venous thrombotic event, and venous thrombotic event in an unusual site. Most guidelines recommend testing for an inheritable thrombophilia and antiphospholipid syndrome when concerning factors are present since the patients are at high risk for inherited thrombophilia conditions (Arachchillage, et al.). This patient has a clinical scenario consistent with recurrent venous thrombotic event. The records suggest that the second episode was an unprovoked event, which raises the likelihood for an underlying thrombophilia. Given the history of intracranial hemorrhagic events in the past, knowing his underlying hypercoagulable status would aid in making the decision in duration of anticoagulation. Overall, this patient would likely benefit from Factor V Leiden mutation testing. Therefore, the requested Factor V Leiden genetic testing is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings: Two of the three physician reviewers found the requested services are likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are likely to be more beneficial for evaluation 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 medical oncology with subspecialty certifications in hematology and internal medicine and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certifications in hematology and oncology and is actively practicing. Physician reviewer 3 is board certified in medical oncology with subspecialty certification in hematology 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 Ozempic 0.25/0.5 mg dose pen. The records provided for review document that this patient has a history of obesity. The patient reports that they engaged in an exercise program in his 20s to help manage his weight. The patients provider has recommended treatment with Ozempic. Gadde and colleagues noted that while lifestyle modification is recommended as the cornerstone of obesity management, many patients do not achieve long-lasting benefits due to difficulty with adherence as well as physiological and neurohormonal adaptation of the body in response to weight loss. There are multiple pharmacologic therapies available for weight management. Wegovy and Ozempic are equivalent members of a class of medications known as glucagon-like peptide-1 (GLP-1) analogs. As noted in the medical literature, GLP-1 analogs have been shown to improve glycemic control, reduce body weight and decrease cardiovascular risk (Knudsen and Lau). Studies have demonstrated Ozempics ability to promote weight loss via reduced appetite and energy intake and delayed gastric emptying (Cornell). For these reasons, the requested medication Ozempic 0.25/0.5 mg dose pen is medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for occipital nerve bocks every four weeks. In this case, the patient has been diagnosed with chronic migraines and occipital neuralgia, which have been refractory to medication management with multiple classes of agents. The provider noted that the patient underwent treatment with an occipital nerve block. The patient was reportedly satisfied with the results, but there is a lack of documentation of percentage of pain relief or duration of benefit. The provider has recommended treatment with serial repeat occipital nerve blocks every four weeks. However, the current evidence regarding the use of occipital nerve blocks is limited given the limited studies showing superiority to standard of care treatments. Barmherzig and Kingston found that, Anesthetic block of the greater and/or lesser occipital nerves are often used both diagnostically and therapeutically. Chowdhury and colleagues found that treatment with greater occipital nerve block was found to be safe and the treatment-emergent adverse effects (TEAEs) were generally mild and transient. The authors concluded that the long-term preventive efficacy of occipital nerve blocks needs to be assessed by further randomized controlled trials. Based on these findings, the requested occipital nerve bocks every four weeks are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings: Three of the three physician reviewers found the requested services 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 requested services are 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 physical medicine and rehabilitation 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 Saxenda solution pen-injector 18 mg/3 mL. Gadde and colleagues note that obesity remains a continuing global health concern. The authors further note that while lifestyle modification is recommended as the cornerstone of obesity management, as many patients do not achieve long-lasting benefits due to difficulty with adherence as well as physiological and neurohormonal adaptation of the body in response to weight loss, there are currently multiple pharmacologic therapies which are available for weight management. Knudsen and Lau report that glucagon-like peptide-1 (GLP-1) analogs, such as Saxenda, improve glycemic control, reduce body weight, and decrease cardiovascular risk. Cornell notes that GLP-1 receptor agonists have an established efficacy and safety profile. These medications promote weight loss by reducing appetite and energy intake and delaying gastric emptying. Given that current medical literature supports the use of the Saxenda in promoting weight loss and the low likelihood of health risks associated with this medication, the requested medication is medically indicated. Therefore, Saxenda solution pen-injector 18 mg/3 mL 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 with sub-specialty 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: The enrollee has requested authorization and coverage for Transcranial Magnetic Stimulation (TMS) (CPT-90867), (CPT-90868 x 34), and (CPT-90869). Findings:  The physician reviewer found that patients who have tried and not responded to multiple classes of antidepressants, the chance of achieving remission from pharmacotherapy is very low. Multiple randomized controlled trials have supported the safety and efficacy of repetitive transcranial magnetic stimulation (rTMs) therapy for severe depression that is non-responsive to pharmacotherapy. Moreover, rTMS appears to have a moderate effect on reducing symptoms of depression. The Food and Drug administration has approved the treatment of rTMs for patients who have not responded to one adequate antidepressant trial in the current depressive episode. The FDA recommendation is consistent with treatment guidelines from the American Psychiatric Association, Canadian Network for Mood and Anxiety Treatments, and the Royal Australian and New Zealand College of Psychiatrists. In this case, the patient has a history of major depression and has not responded to multiple classes of antidepressants and psychotherapy. Records reflect that the patient had a robust and positive response to rTMS between 2019 and 2020. Treatment with Transcranial Magnetic Stimulation is in accordance with the generally accepted standards of mental health care. Treatment with Transcranial Magnetic Stimulation is clinically appropriate, and it is 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. Accordingly, the requested Transcranial Magnetic Stimulation (TMS) (CPT-90867), (CPT-90868 x 34), and (CPT-90869) is medically necessary to treat 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 medically necessary as defined in Health and Safety Code section 1374.72(a)(3)(A). 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: An enrollee has requested authorization and coverage for Lantus insulin in a pen formulation.Since the introduction of insulin as a life-saving agent for patients with type 1 diabetes, insulin preparations have evolved to approximate physiologic insulin delivery profiles to meet prandial and basal insulin needs. Basal insulins, such as Lantus, are designed to have a protracted time-action profile to facilitate basal glucose control over 24 hours. Though many patients with type 2 diabetes can manage their condition with oral agents, initiating insulin therapy with a basal insulin analogue has become a standard of care in the treatment of type 2 diabetes mellitus. While most patients use prefilled insulin pens to administer Lantus (and other insulins), it is also available to be administered from a vial with a syringe. Medical literatures have shown that using an insulin pen device is associated with increased therapy persistence and adherence, and lower hemoglobin A1C levels relative to vial/syringe, without increasing total all-cause or diabetes-related costs. In this patients case, the pen is even more important, as she is required to travel to high human traffic areas where there are developmentally disabled children and adults, and a pen is therefore a much safer option. Under these circumstances, the requested Lantus insulin in a pen formulation is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary to treat the patients medical condition. Therefore, the Health Plans denials 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.